After completing my postgraduate training in 2007, I started my career as an Assistant Professor of Psychiatry at Kurnool Medical College. Initially, my mind was filled with evidence-based treatment guidelines from NICE (National Institute for Health and Care Excellence). I often expressed my arrogance and made funny remarks about the treatments prescribed by my seniors. I still feel guilty about this and often meet them at seminars to apologise.
Over time, I learned that real-world treatment often differs from guidelines, requiring constant tweaks and, at times, entirely new strategies. No book can fully capture the realities of clinical experience. Much of it is learned from professors and colleagues through humble discussions. In day-to-day practice, everyone—from the nursing orderly and patient attendant to the patient and senior consultant—is a teacher.
One of my most memorable experiences involved a husband who came to me seeking advice about divorcing his wife. He was frustrated because his wife was not responding to treatment. I asked them to return with all her previous medical records. The couple and their parents came to the outpatient department together.
The wife’s parents started blaming the husband and his parents for her illness. The husband’s parents, in turn, complained that the illness had been concealed from them. The room was filled with anger, despair and mistrust. After listening to everyone, it was difficult for me to understand who was actually unwell.
After nearly two hours of listening, one statement from the wife caught my attention: “My husband infected me with diseases, and all my physical symptoms are because of his sexual talk on the phone.”
I was convinced that this was a delusional belief. When I reviewed her treatment history, I found that she had been treated with multiple antipsychotics for prolonged periods, with good compliance. The only antipsychotic she had not received was clozapine.
I decided to start clozapine, but I was apprehensive. What if she developed neutropenia? What about cardiac complications? How would I convince the family to travel 200 kilometres regularly for blood tests?
I called my senior and asked what I should do about the weekly blood tests. He simply said, “Ask them to get the tests done at a local laboratory. They can call you and report the results.”
That simple piece of practical advice gave me the confidence to proceed.
After six months of treatment, everything was well. The family withdrew the divorce petition.
My success in this case, I believe, was not merely in prescribing clozapine. It was in helping the family understand schizophrenia as an illness—like hypertension or diabetes—where treatment is medical care, not divorce.
Success in psychiatry lies in improving our listening skills. The rat race to see 50 or more patients a day may ultimately do more harm than good. Psychiatry is, at its heart, about listening and empathy.
Clozapine remains a feared drug because of its potential side effects. But careful monitoring and appropriate management of these risks can save lives—and sometimes, as in this case, families too.
(The above article has previously appeared in MINDS newsletter, Volume 11, Issue 10, October 2021)
Dr. Vijaya Chandra Reddy Avula
Professor
Department of Psychiatry
All India Institute of Medical Sciences, Mangalagiri (Andhra Pradesh)
