Stranded in San Francisco.

In August, 2005, a 51-year-old unemployed, divorced man was brought by ambulance to our emergency department, after being found unconscious in the hallway of the hotel where he lived alone. On arrival at hospital, he had regained consciousness. He reported that small purple patches, which were not painful or itchy, had appeared on his left buttock a month before; the patches had grown, and coalesced into a large “bruise” that extended down his leg. The patient also reported severe light-headedness, and daily episodes of fainting on exertion. The patient had not received medical care for several years. He reported no previous illness, and was taking no medications. He denied using illicit drugs or consuming alcohol. We observed scleral icterus, gingivitis, a small, oozing laceration above the upper incisors, and a widespread, ecchymotic, purpuric rash (fi gure). The patient had severe orthostatic hypotension, and tangential speech. Faecal-occult-blood testing was positive. Blood tests showed normocytic anaemia, a packed cell volume of 24%, an unconjugated bilirubin concentration of 94 μmol/L, and a creatinine concentration of 150 μmol/L due to dehydration. The clotting screen showed nothing of note. Urinalysis was strongly positive for haemoglobin and ketones, weakly positive for bilirubin, and showed 0–2 red blood cells per high-powered fi eld. On further questioning, the patient stated that, for months, he had eaten only canned tuna and crackers. The serum concentration of ascorbic acid was undetect able, and histopathological analysis of a skin biopsy sample showed perifollicular haemorrhage, confi rming the diagnosis of scurvy; we deduced that the high bilirubin concentration was caused by haemolysis possibly occurring within bruises and intravascularly . We prescribed ascorbic acid (200 mg, four times a day); the patient’s rash and lightheadedness resolved within 2 weeks. In a psychiatric interview, the patient explained that gangsters had put amphetamines in his food, and might kill him for eating anything other than tuna and crackers. The psychiatrist concluded that these beliefs were delusional, and also noted thought disorder, fl attened aff ect, and social withdrawal. He diagnosed schizophrenia, and prescribed ziprasidone. A social worker contacted the patient’s family, whom he had not seen for years; the patient was discharged to supported accommodation. He continued to have persecutory thoughts about food, but ate what his family and carers gave him. He became depressed, sleepless, and thought of jumping off a pier. Ziprasidone was replaced with risperidone, then quetiapine. The patient was also treated with citalopram. He was given regular group and individual psychotherapy. His psychosis and depression resolved. When last seen by us, in June, 2007, he was able to care for himself, although he received support from a social worker in managing his fi nances. He ate well—and, indeed, became overweight, consistent with his drug regimen. Our patient was the third and youngest child of lowincome Irish immigrants, with a family history of depression. He was a popular athlete in high school. As a young adult, he had occasionally used LSD and marijuana. After dropping out of college, he worked as a laboratory technician and in local government, got married, and had two daughters. At 25 years of age, he was having diffi culties at work when he was arrested after a brawl at a policeman’s stag party. His trial was stressful, partly because of a public backlash against the police. He lost all his money, his wife left him, and he became homeless in his thirties. He gradually lost contact with his family. In the USA, most people receive health insurance through their employer. Hence, people who lose their jobs can lose access to health care until they have become seriously unwell. People with mental illness are especially likely to lose their social network, and have diffi culty accessing health care. Even among people who apparently have a high genetic risk of schizophrenia, it seems that circumstances create mental illness; social support and relationships can be crucial to preventing it, or facilitating recovery.