Date post: | 15-Jan-2016 |
Category: |
Documents |
Upload: | harvey-long |
View: | 212 times |
Download: | 0 times |
“The way to recovery”
GAMIAN-Europe /Eastern Europe Regional Seminar
““The way to Recovery: The way to Recovery: Pharmacotherapy, Psychotherapy Pharmacotherapy, Psychotherapy and Social Rehabilitation from the and Social Rehabilitation from the
clinicians’ perspective”clinicians’ perspective”
Dr. F. Cañas de Paz
H. “Dr. R. Lafora”. Madrid. Spain
Bucarest, may 23th 2009
Positive SymptomsHallucinationsDelusionsHostilityExcitability
Negative SymptomsBlunted emotionsAnhedoniaLack of feelingLoss of motivationSocial withdrawal
CognitionVerbal Memory Executive functionAttention
Mood SymptomsDepressionManiaPoor insight
FUNCTION
Spectrum of Symptoms in Severe Mental Disorders (SMD)
CRITICAL PERIOD
Birchwood M et al. Br J Psychiatry 1998;172 (S 33):53-9.
Cronic-relapses
Age (years)
0
10
20
30
40
50
60
70
80
90
100
20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Level of
fun
cti
on
ing
(%
)Differing courses following a first psychotic
episode
Partial response
Breier et al. Am J Psychiatry 1994;151:20–26.
Remissión-recovery
Response
Prodromal
1st episode
Relapses can have devastating consequences
Psychosocial consequences
Psychosis “toxicity”?
RECOVERYRECOVERY
1. Symptoms no longer interfere with daily life
2. Person can engage in meaninful actitivies (role fullfilment):1. Self-care2. Relationships3. Work / school
Key issue: The ability to form and sustain social relationships
Effective SMD Treatment Requires an Holistic Approach
Positive Symptoms
Negative Symptoms
Mood Disturbance
Cognitive Dysfunction
Minimising and treating side effects Encouraging
medication adherence Employment
opportunities/sources of
income
Encouraging adequate housing
Managing sleep
disturbances
Managing substance
misuse
Monitoring physical health
Integrating care teams
Involving family
Educating and informing
Why Early Identification and Treatment Matters
>70% of first-episode patients achieve full remission of
psychotic symptoms within 3–4 months1
>80% achieve stable remission at the end of 1 year1
Delayed initiation of antipsychotic medication results in
poorer outcomes:2
– More severe and persistent positive and negative symptoms
– Poorer treatment response
Recurrent episodes of psychosis associated with:3
risk of chronic residual symptoms
– Evidence of anatomical neuroprogression
1. Lieberman et al. Neuropsychopharmacol. 1996;14:13S–21S; 2. Haas et al. J Psychiatr Res. 1998;32:151–159; 3. APA Practice Guideline 2004
Overt
Covert
Non-adherence
Relapse
Partial-adherence
Relapse
Partial response
Fluctuates
IN THE FIRST YEAR OF TREATMENT: 39% non-adherent; 20% inadequately adherent Coldham EL et al. Acta Psychiatr Scand 2002;106:286-90.
POOR POOR ADHERENCEADHERENCE
ADHERENCE IN SMD
PATIENT RELATED:• insight• cognitive impairment• beliefs• doctor-patient relationship• substance abuse
MEDICATION RELATED:• cost• side effects• dosing schedule
Between 50% and 80% do not
believe that they have a disorder,
or that they require ongoing
treatment.
Dam J. Nord J Psychiatry 2006;60:114-20
Do We Really Know How Compliant Our Patients Are?
In a recent survey across Spain…
Only 43% of psychiatrists (n=844)
believed their patients were compliant
82% of relatives (n=796)
believed the patient was usually compliant
BUT
95% of patients (n=938)
said they regularly took their medication
Giner et al. Actas Esp Psiquiatr. 2006;34:386–392
Strategies for Improving Medication Adherence
Adapted from Perkins. J Clin Psychiatry 2002;63:1121–1128
Patient-related issues
Cognitive therapy
Educate about the illness and benefits of treatment
Memory aids
Involvement of patient in therapeutic alliance
Treatment-related issues
Minimise complexity of treatment regimen
Titrate to optimal dose
Minimise impact of side effects on patient’s life
Provide clear instructions on medication use
Select antipsychotic with minimal EPS, weight gain and prolactin effects
Recognising Relapse in SMD
Many patients have ‘early warning signs’ of an impending
psychotic relapse
– 2 days–4 weeks before onset of frank psychosis
Dysphoric symptoms most commonly reported
– Depressed mood, withdrawal, sleep and appetite problems
Patients’ ‘relapse signatures’ should be identified and noted
– Timely and effective intervention may arrest progression
Families play a key role in recognising early warning signs
Birchwood et al. APT 2000;6:93–101
Some Early Warning Signs of Psychotic Relapse
Birchwood et al. APT 2000;6:93–101
Thinking/perception Feelings Behaviours
Racing thoughts Helpless or useless Difficulty sleeping
Senses seem sharper Irritable Jumbled speech
Special powers Sad or low Talking to yourself
Mind being read Anxious or restless Neglecting appearance
Messages from TV/radio Religious obsessions Social withdrawal
Cannot make decisions Being watched Not eating
Hearing voices Isolated Child-like behaviour
Poor concentration Loss of trust Aggression
PREDICTORS OF TREATMENT OUTCOMEPREDICTORS OF TREATMENT OUTCOME
POORPOOR OUTCOMEOUTCOME
Poor
premorbid
adjustment
Male sex Early age
of onset
Poor
medication
adherence
Reduced brain
volumeCognitive
impairment
Inherent
refractoriness
Longer
duration of
untreated dis.
MODIFIABLE FACTORS
Robinson et al, 2004; Emsley et al, 2006
PSYCHOSOCIAL REHABILITATIONPSYCHOSOCIAL REHABILITATION
A mixture of skill (re)acquisition and support needed to maintain a person in community (A. Williams)
DYNAMIC PROCESS: SKILLS SUPPORT
Medical Education Meeting – FUM IV ‘The adherence challenge’May 12, 2009 Brussels
Medical Education Meeting – FUM IV ‘The adherence challenge’May 12, 2009 Brussels
CONCLUSIONS (1)
1. The goal in SMD treatment is recovery
2. The main poins to arrive there are:a) Early interventionb) Treatment adherencec) Relapse preventiond) Psychoeducatione) Rehabilitation and social supportf) Work / independency
CONCLUSIONS (2)
To obtain that is important:
• Reduce stigma• Engage patients (shared decission model)
and families• Organize access and countinuity of care• Mobilize social resources