Transcript Graham Scott ii mtg 8/9/98

Managing Chronic Mental
Illness in Primary Care
The “recovery” model of managing
serious mental illness
Prognosis for Recovery
Tools and frameworks for promoting
recovery in Primary Care
Self-management
Motivational interviewing
Relapse prevention plans/”advance
directives”
Modern Antipsychotic medications
What is Recovery
As defined by consumers
“Having a life worth living”
“Living well in the presence or absence of
symptoms of mental ill-health”
As defined by a leading expert in
recovery-oriented MHS:
“Living in stable accommodation, paying
taxes, and having a social life”
What is the “Recovery”
Model
 Equivalent for MHS of the “Self-Management”
model of chronic care management in Primary
Care (e.g., Flinders model)
 Optimal clinical care is a necessary but not
sufficient condition of recovery –
 Recovery as a personal journey, taking selfresponsibility central to this process
 Critical place of hope and positive expectation of the
future (cf, past “therapeutic nihilism” re chronic
mental illnesses such as schizophrenia)
Clinician Role in Recovery
Ongoing provision of education and
information
Fostering hope
Encouraging self-responsibility
Working collaboratively:
“You need medication to stop hearing
voices”
vs
“You want to work, you say voices interfere
with work, medication may help make this
manageable so you can work”
Clinician Role in Recovery
Understanding “insight” in a MH context:
NOT a one-dimensional concept as
traditionally taught – “lack of insight” in
psychiatry, vs. “denial as a helpful strategy” in
medicine
Adjustment to psychosis as a serious illness,
occurs over time as with any illness
“Forced” insight can actually precipitate
suicidal thinking/behaviour – being
“overwhelmed” by insight
Clinician Role in Recovery
Recovery – the power dynamic
Enforced treatment - clinician takes
responsibility, impedes recovery
Vs
The right to learn from mistakes – being
supported through a process of stopping
medication, and learning from the
consequences of this – shared responsibility,
facilitates recovery
Psychotic Illness Prognosis
Vermont Longitudinal Study:
Followed patients discharged from a US state
mental hospital for up to 30 yrs
With time, most made substantial degrees of
recovery – lived independently, worked etc.
Challenged the prevailing notion of
chronicity/incompetence of patients with
psychotic illnesses
Recovery – the Evidencebase
Largely qualitative research:
Being supported to live in own home gives better
outcome than “residential rehab” placements
Being supported to maintain employment reduces
service utilisation by up to 2/3
Recovery narratives – common themes of
regaining hope, having “someone care and
believe in you”, being supported to regain selfresponsibility, establishing meaningful relationships
Recovery – the Evidencebase
What people with severe mental illness
want… Support to Live in their own home
Work
Have a reasonable income
Have social relationships…
…in other words the same as everyone else
Key Services for Recovery
Support-type relationship(s) within which
trust can build, understanding of “what
will make a difference” be built, and
based on this care be co-ordinated
Supported housing
Supported employment
Good collaborative clinical care
Outcome from Discharge
to GP for People in Recovery
Many studies of outcome following
transfer back to Primary Care Mental health and level of function
outcomes equal
Physical health status improved
Patient/family satisfaction greater
GP satisfaction high if Access to training for the role
Ready access to specialist support/advice
Tools for Ongoing Primary
Care Use
Relapse prevention plans:
Recognising the “relapse signature” – typical
earliest signs of impending relapse - to allow
earliest possible intervention
Developing a shared plan that recognises and
responds to this (see handout for example)
Often useful to have a clear “advance directive”
allowing the person to influence care in the case
of a significant relapse (eg, preferred/most
effective medications, best setting for care, use of
mental health act if that has been helpful etc.)
Tools for Ongoing Primary
Care Use
Fostering Self Management –
ongoing education re the condition,
 support to develop a sense of control over
the condition
self-care strategies (sleep, diet etc.)
self-help strategies (exercise, activity
scheduling etc)
encouragement with medication adherence
Tools for Ongoing Primary
Care Use
Motivational Interviewing – useful as part
of fostering good “self management” as
with any chronic health condition
New Generation
Antipsychotics
Medication
Risperidone
Olanzapine
Quetiapine
Aripiprazole
usual dose range
1-6 mg
2.5-20 mg
100-900 mg*
5-30 mg
* Useful sedative/anxiolytic at 25-75 mg
New Generation
Antipsychotics
Benefits –
Equal antipsychotic effect to older drugs
Better at reducing mood symptoms and
cognitive impairments
Also reduce negative symptoms (poor
motivation, social withdrawal, poor self-care,
blunted affect etc)
New Generation
Antipsychotics
Side Effects:
Generally better tolerated than older
antipsychotics
Don’t cause prominent EPSE (NB –
Risperidone CAN sometimes cause EPSE esp
at higher doses)
DO cause set of metabolic changes –
“Metabolic Syndrome” – weight gain,
hypercholersterolaemia, impaired glucose
metabolism – Olanzapine worst, Aripiprazole
best in this regard
Metabolic Syndrome
 Is the major issue in the long-term drug treatment of
psychotic illness
 One of major causes of average 15-20 yrs lower life
expectancy of psych patients
 Manage as for this syndrome in any patient
 Early identification
 Review medication options
 Promote lifestyle changes – diet, exercise, smoking
 Treat as indicated
 …Recognising challenges of this with this popn