treatment for schizophrenia and other severe mental disorders

institutional care in the past

move from asylums toward large mental hospitals

-moral treatment (human, sypathy)

-state hospitals (public MH hospitals) for patients who could not afford private care

orercrowding and understaff

-restrain, isolation, neglect, abuse, lobotomy, social breakdown syndrome

social breakdown syndrome

happened when institutions became overcrowded

agression, social withdrawal

institutions now

many people who would have been in them then are now in nursing homes, prisons

MH care is minimal in these settings

luecotomy

two holes were drilled in either side of the skull, instrument (like an icepick) was inserted into brain tissue to destroy nerve

lobotomy

needle through eye socket and rotated to destroy tissue

caused brain seizures, weight gain, loss of motor control, paralysis, incontinence, poor intellectual and emotional responsiveness (quiet and sit in corner, is that succes?)

milieu therapy

1950s (maxwell jones)

cannot help patients unless social climate promotes productive activity, self-respect, and responsibility (jobs)

live in therapeutic community of respect, support, openness

some need sheltered aftercare

often combined with other community programs

token economy

operant conditioning

given reward (token) for good behaviors and allowed to exchange for rewards

reduce psychotic and related behaviors

limits of token economies

hard to generalize, everyone’s behaviors look different

ethical and legal concerns around basic needs

slippery slope (expect rewards for everything)

wont be like that in real world

antipsychotic meds discovery

1950s

led to stop of lobotomy

discovered antihistamine (allergy) drugs

antihistamines (phenothiazines) calm before surgery

chlorpromazine (phenothiazine) tested on psychosis and reduced symptoms-calm

in 1954 chlorpromazine (thorazine) approved for sale as antipsychotic drug

first gen antipsychotic drugs

also known as neuroleptic drugs 

act on d-2 receptors (block dopamine)

target little negative symptoms but reduce positive symptoms

second gen antipsychotics (atypical)

target more negative symtpoms as well

recieved at fewer d-2 receptors, more d-1, d-4 and serotonin than others

at least as effective, often more

cause fewer extrapyramidal symptoms and less tardive dyskinesia

effectiveness of antipsychotics

reduce symptoms in about 70% of patients

more effective than any other approach used alone

maximum level of improvement within first 6 months of treatment

pos symptoms reduced more completely or more quickly

high relapse rate when stop taking prematurely

unwanted effects of first gen antipsychotic drugs

extrapyramidal effects

-parkinsonian and related symtpoms: slow, shuffle, rigid, stiff, from reduction of dopamine

-neuroleptic malignant syndrome: protentially fatal reaction, mainly in older adults (confusion, fever)

-tardive dyskinesia: similar to psychotic symptoms and often overlooked; grimaces, lip smack, blinking, jerking

prescribing 1st gen drugs

now more careful

lowest effective dose (go up if needed)

gradually reduce or stop meds weeks or months after patient begins functioning

many symptoms dont return

if patients dont improve when prescribing 1st gen…

trial and error, increase dose, add additional drug (synergistic/polypharamcy), stop drug and try alternative one or stop all meds

polypharmacy

adding additional drugs to antipsychotic to produce synergistic effect,

do this when patient is not improving

unwanted effects of 2nd gen antipsychotics

risk of a life-threatening drop in white blood cells (agranulocytosis)

may cause weight gain, dizziness, significant elevations in blood sugar

psychotherapy

rare before antipsychotics

now- more common and successful

-cognitive-behavioral

-sociocultural

cognitive-behavioral therapies

cognitive remediation

new-wave cognitive-behavioral therapies

cognitve remediation

CBT

focuses on difficulties in attention, planning, and memory

jobs, skills, plan day, navigation

provides increasingly complex computer tasks until planning and social awareness tasks are reached

provides for moderate improvement-attn, planning, memory, problem-solving, structure, skills, social realtions

new-wave cognitive behavioral therapies

CBT

hallucinations should be accepted rather than misinterpreted or overreacted to

help clients accept their problematic thoughts, gain a greater sense of control, become more functional, and move forward in life, build relationships

family influence

sociocultural

many recovering live with family members

significant stress on family

if they live with members who display high levels of expressed emotions (EE), they are at greater risk for relapse than those who live with a more supportive or positive family

family therapy

address family-related issues, create more realistic expectations, education and empathy emotional support

when combined with drug therapy, helps relapse rates and readmissions go down

family support groupd and family psychoeducation programs

-provide encouragment and advice

-usefulness not fully scientifically determined

coordinated specialy care (CSC) psychotherapy

originally called social theray

addresses social and personal difficulties in clients’ lives

practical advice, problem solving, decision making, social skills training, medication management, employment counseling, financial assistance, housing (someone may come to house)

research shows that this reduces rehospitalization

community mental health act

1963

ordered that patients with a variety of psychological disorders should be released and treated in the community

stipulated patients should be offered a range of services (step down program, mobile vehicles)

part of deinstitutionalization process

inadequate quality of community care creates a “revolving door” pattern for many patients

coordinated services (effective community care, assertive community treatment)

coordinated services

-community MH centers provide meds, psychotherapy, inpatient emergency care

-important for those with dual diagnosis

short-term hospitalization (effective community care, assertive community treatment)

-short term hospital programs

-up to a few weeks, released to aftercare programs for follow-up

-safe space

partial hospitalization (effective community care, assertive community treatment)

if the patietn needs fall between full hospital and outpatient care, day center programs may work

daily supervised activites and programs to improve social skills

semihospital (residential crisis center) houses or other structures provide 24 hour nursing care for patients 

supervised residences (effective community care)

halfway houes (group homes) provide shelter and supervision for patients unable to live alone or with families, but dont require hospitalization

staff=paraprofessionals (trained)

houses are run with a milueu therapy

prgorams help them adjust to community life (independence) and avoid rehospitalization

occupational training and support (effective community care, assertive community treatemetn)

paid employment provides income, indepedence, self-respect, and stimulation of working with others

many recieve it in a sheltered workshop

vocational agensies and ocunselors may provide supported employment opportunities (shadow)

community treatment failure

fewer than half of all people who need them recieve appropriate community MH services

lack of access, dont think they have an issue, poor coordination of services, shortage of services

promise of community treatment

research indicates that clients in effective community programs make more improvements than those in other kinds of treatment or poor community programs

worldwide push for well-coordinated community treatment is considered crucial solution to problem of mental dysfunction (NAMI- awareness)