Psychological medicine

Treatment of Mental Illness

Care for the Mentally Ill

  • Illness (especially initially) is very traumatic for individual and family (eg may not cope as normal or remember anything you say)
  • Families will often blame themselves or feel guilty
  • Knowledge/education is key: without it people are powerless 
  • „Recovery‟: issue may not be getting rid of all the symptoms, but getting rid of or managing those symptoms which are disruptive or distressing

Stigma

  • Feeling created by stigma is a significant reason for the loss of hope and relapse experience by those with mental illness
  • Stigma leads to discrimination and sense of shame
  • Common misconceptions:
    • People with mental illness are dangerous and violent 
    • People with mental illness never recover: vast majority do recover, some require ongoing treatment
    • It‟s got nothing to do with me: but mental illness affects people of all ages and backgrounds

Drug Treatment

  • When using medication:
    • Don‟t make assumptions about what people want – ask them
    • What have they used before and what has worked.  What‟s worked for family members? 
    • Need to consider side effects: will benefits outweigh costs. Side effects are often significant, and will be a major cause of problems with compliance. Be ready to change medications if side effects are intolerable 
    • Need to consider the long term (ie when/how will they come off) as well as the short-term
    • Make sure alternative/adjunct treatments are considered 
    • Optimal initial dose: the level at which there are maximum therapeutic benefits for minimum side effects 
    • Maintenance dose: lowest possible dose that provides relief/remission. Will vary from person to person, and due to psychosocial factors (ie may need to increase it under when under stress)
    • Regular review is important, until the patient is stabilized on the medication
  • Drug education:
    • Understanding the medication‟s purpose is vital to informed consent and to adherence to treatment 
    • Patient needs to know why the medication is needed, what the medication is expected to achieve, when and how to take it, and possible side effects or restrictions (eg diet), the likely duration of treatment, how long until an effect should be noticed, whether the medication is addictive, what are the alternatives 
    • Some medication (eg fat soluble anti-psychotics) clears very slowly from the body, so a patient can stop taking them without immediate relapse. Patient‟s need to understand that the drugs are effective only if taken regularly

Cognitive Behavioural Therapy (CBT)

  • Was developed as a structured, problem-orientated psychotherapy by Aaron Beck in the 1960s 
  • Focuses on cognitive and behavioural influences on human experience, as well as interpersonal processes and „unconscious‟ motivation/underlying schema
  • Draws on my aspects of learning theory and cognitive psychology 
  • Process in depression: early experience ® formation of dysfunctional assumptions ® critical incident ® assumptions activated ® negative automatic thoughts ® behavioural, motivational, affective, cognitive and somatic symptoms of depression
  • Cognitive triad in depression: negative view of self, of the world, and of the future
  • Basic principals of CBT:
    • The situation itself does not determine how people feel
    • Emotions and behaviours are influenced by how people perceive events
    • Information processing biases lead to, or maintain, depressed affect and behaviour
  • Efficacy of CBT well supported.  At least as effective as antidepressants in depressed outpatients

 Problem Solving Therapy

  • For „problems of living‟ causing or contributing to current symptoms 
  • Regaining control ® ­mood and less overwhelmed
  • 3 Steps:
    • Realise symptoms are linked to problems in their life
    • Define and clarify problems
    • Solve problems in a structured way
  • Stages:
    • Explanation of treatment and it‟s rationale
      • Recognition of emotional symptoms
      • Recognition of problems: eg relationships, work, money, housing, legal, alcohol, etc
      • Acceptance of a link between symptoms and problems
    • Clarification and definition of problems:
    • List problems in a concrete form
    • Break down big problems into more manageable parts
  • Choose achievable goals given patients resources and obstacles
  • Patient generates as many solutions as possible
  • Choose the preferred solution
  • Implement the preferred solution – set deadlines, etc 
  • Evaluation and encouragement. If unsuccessful consider: low motivation, inappropriate goals, unsuitable choice of solution, inappropriate implementation

Compulsory Treatment

  • See also Topic: Protection of Personal and Property Rights Act (1988). Used for people with diminished competence – especially dementia.
  • Features of the Mental Health (Compulsory Assessment and Treatment) Act 1992:
    • Specific legal definition of mental disorder (not a diagnostic definition) 
    • Even if committed, must be treated in the least restrictive environment (® community orders) 
    • Rights of patients are listed: eg to information, to respect for culture, to second opinion, to legal advice, ability to communicate (phone, letters, visitors, etc)
    • Can‟t treat without consent (which you must try and get) without a second opinion
    • Review procedures are specified, including the Mental Health Review Tribunal
  • Definition of Mental Disorder (Section 2): 
    • An abnormal state of mind characterised by continuous or intermittent delusions, disorders of mood, volition (energy, drive, will), cognition, or perception, etc 
    • And to such a degree that it poses a serious danger to person or others, or seriously ¯ ability to take care of themselves 
    • Exclusions include (Section 4): if due only to intellectual disability or substance abuse, criminal behaviour, sexual preferences, political and religious views
  • Process:
    • Application must be made by anyone over 18 (section 8)
    • Medical certificate must be provided by any doctor (who may be the applicant, section 8)
    • Reviewed by a psychiatrist designated under the Act within 24 hours (section 9) 
    • 5 day compulsory assessment period (although can be released, become voluntary, appeal, section 11) 
    • Following reassessment can be held for a further 14 days (section 13)
    • To extend beyond this require review by family court
    • Compulsory treatment orders:
      • Community treatment orders (section 29)
      • Inpatient orders (section 30) 
    • Duly Authorised Officer = usually an experienced CPN in CATT team – carry out assessments, start process