The Patient Declined – Caregiving Mothers Must Be Partners in Mental Health Care in Nova Scotia

A recent remarkable essay etitled “The Patient Declined” appearing in The Lancet Psychiatry should be required reading for every physician caring for people with serious mental illness.

The essay offers a powerful reminder of why family caregivers must be essential partners in the assessment, treatment and recovery of people living with serious mental illness.

Patrick William Kelly writes from the perspective of a patient who, during years of severe mental illness, could speak coherently, understand information and give carefully reasoned explanations for refusing treatment. What Patrick could not recognize was that he was seriously mentally ill.

Patrick’s mother knew that he was severely ill. But she was kept outside the clinical process by treating clinicians.

Patrick describes exactly the desperate situation that many caregiving mothers in Nova Scotia experience. His mother would be expected to care for him after discharge—to help keep him safe, manage medications and get him to appointments—while being excluded by clinicians and the health system from obtaining vital information that she would need to properly care for Patrick.

Unfortunately, caregiving mothers of adult children in Nova Scotia also find themselves regarded as bothersome or unqualified and excluded from the assessment process by the treating physicians, while at the same time being considered, by the very same clinicians, as fully qualified and expected to manage the discharge plan.

Just how unreasonable can clinicians be !

When illnesses such as schizophrenia or bipolar disorder impair a person’s ability to recognize that they are ill—a condition known as anosognosia—the patient’s account may be sincere and believable but still lack vital information that enables clinicians to understand what is actually happening.

How can clinicians get that vital information?

Very easily - often it is a caregiving mother who knew the person before the illness; the person who noticed the changes in behaviour; the person who knows whether medication is actually being taken; and perhaps the only person in the world who will still be there with the loved one long after the meeting with the clinician has ended.

That information can be essential clinical evidence that a clinician requires to make an accurate clinical assessment.

Confidentiality and privacy of information are essential and are rights of every person, including the loved one. Families do not have an automatic right to confidential personal information about an adult patient’s medical care, nor should they be heard simply because they disagree with the patient’s decisions.

On the other hand, clinicians can—and in some circumstances may need to—solicit information from families even when there are limits on what they can legally tell families in return. In his article, Patrick makes precisely this distinction and argues that collateral history should be actively sought as a routine component of assessment when impaired insight is suspected.

For years, caregiving mothers in Nova Scotia have told us that they approach clinicians with information they believe to be crucial, only to encounter a shield labelled “privacy.” They can be left with the impression that privacy provides a convenient reason for clinicians or clinic administrators simply to refuse communication with caregiving mothers.

Mothers should not and will not continue to accept this as the standard of compassionate and collaborative mental-health care in Nova Scotia.

Patrick ultimately credits his recovery not only to medication and therapy, but profoundly to rebuilding his relationship with his mother. Ironically, the same person excluded by clinicians from his treatment became the one person central to Patrick's recovery.

Dr. Denis Riordan
Nova Scotia Moms for Compassionate & Collaborative Mental Health Care

Credit: for the essay by Patrick William Kelly see - The Lancet Psychiatry, “The Patient Declined,” published online August 19, 2026.
DOI: 10.1016/S2215-0366(26)00269-5