The Severely Mentally Ill Patient

=Executive Summary= =Objectives=
 * Atypical antipsychotics show clear efficacy in treating some symptoms of schitzophrenia, however, a comprehensive therapeutic approach focusing on social problem solving, employment skills, and family involvement needs to be incorporated into the care of patients.
 * Family involvement reduces relapse rates.
 * Many types of social programs show significant improvement but those gains are only maintained while therapy is ongoing and are unlikely to become permanent skills. Therapy programs are diverse, but tend to be costly and intensive.

Describe how the symptoms of chronic and severe mental illness can impair activities of daily living.
Full recovery of schizophrenia is uncommon, and therefore relapses typically occur. In adiition, complete control of psychosis with medication does not mean normal social and occupational functioning. Negative symptoms are residual, and separate patients from their community. The required reading focuses mainly on employment and “social adjustment”. Anti-psychotics are aimed to control psychosis, but many schizophrenics have never gained social aptitude due to their illness (it often begins in early adulthood) or have lost it due to hospitalizations, etc. The anti-psychotics cannot aid these, so social rehabilitation is often necessary and should be a part of any schizophrenics treatment.

Professionals

 * Psychiatrists – Diagnose condition and prescribe medications
 * Nurses – all work done in the hospital
 * Social Workers – do social worker stuff (housing, aid, groups, etc.)
 * Vocation/rehabilitation specialists – see section on social support therapy
 * Case managers - Critical to identify patient specific needs and referring appropriately for help. More effective for mild to moderate mental illness.
 * Severe (schizophrenics) patients need more intense intervention with hands on coordination of multiple professionals to achieve successful care. The Assertive Community Treatment model, which has a team both in the clinic and in the community (home delivery of meds, proactive monitoring of mental health, in vivo social-skills training and frequent family contacts), achieved significantly fewer hospitalizations, more employment (sheltered, not competitively obtained), more independence and less family burden in patient care with no difference in treatment costs compared to a control group of ‘standard care’.  These benefits were not sustained once discharged from the ACT program (mental illness is chronic disease).  Cons – less self determination in ACT patients.

Family
Schizophrenia used to be blamed on the parents not bonding with their children. This is hooey. Underdeveloped nations with a better family dynamic report better outcomes for schizophrenia than western cultures. Multiple reasons/confounders as to why. Including the family in the rehab of a schizophrenic shows strong benefits in reducing relapses. This can be as simple monthly meetings (but continued for >9 mo), no need for intensive family-provided therapy at home. Including the family has been shown in multiple studies to superior to no psychosocial interventions
 * Randomized trials show a superiority of individual personal therapy (that was problem solving in nature (over family based therapy).

Describe specific treatment interventions that can affect (positively and negatively) psychiatric rehabilitation and community adjustment for patients with severe mental illness.

 * Involving the family with treatment reduces relapses
 * Assertive Community Training
 * deliver care at home proactively, rather than waiting for ER consults. Delivered better outcomes regarding relapses, employment (sheltered employment), independence, and family burden.  Cons are that patients have less self-determination, may be ‘going through the motions’, and are therefore not as ‘socially adjusted’ because they are dependent on their program.


 * Basic Social Skills Model
 * break complex social scenarios down into steps, teach those steps to the patient, practice the steps, put it all together and try it out. Demonstrated to lower relapse rates (30%) versus medication alone (46%) at 1 year.  Lasts only as long as therapy is being performed – no lasting improvements.  In fact, needs weekly implementation as biweekly is no good.  Cons – no impact on ‘social adjustment’.


 * Social Problem Solving Model
 * teach social problem solving, rather that memorizing steps to perform like Basic model. Gives a small but significant improvement in outcomes over Basic model (more possessions, able to prepare own food better, can handle money better) with some lasting effects after therapy ended.  This means a possible improvement in ‘social adjustment’.


 * Cognitive Remediation
 * Find specific cognitive deficits for the patient and focus on training those. For schizophrenia, this means attention, memory and planning.  Demonstrated to provide some overall improvements, but couldn’t predict which deficits in particular could be remedied (i.e. outcomes better but not as good as expected).


 * Supported Employment
 * Schizophrenics are likely to get fired or be unemployed (unemployment rate ~80%). Having a job can be very therapeutic for a schizophrenic patient.

Sheltered employment (special gov’t funded jobs in communities i.e. “McJobs at McDonalds”) continue today but gives no improvement in obtaining competitive employment. Supported employment screens patients for skills, and then funnels them to ‘outside’ jobs where they receive on-the-job training. This approach is showing promise and patients (58%) can find competitive employment. However, these jobs do not seem to be permanent, with up to 71% termination rates on follow-up.
 * Individual Psychotherapy
 * Used to be the gold standard until proven less successful than supportive care in the 1960’s. New versions of personal therapy are showing better success.
 * Focus on different stages: initial --> focus on stress and symptoms, intermediate → learn to relax and reframe when stressed, advanced → seek social and vocational incentives in the community. Clearly show improvements in social adjustment, but no change in relapses

=References=