Treatment and recovery in mental health

NICE guidelines and service user perspectives

Katherine Darton

outline

• Standard diagnosis and treatment in psychiatry

• Schizophrenia as an example - symptoms- treatments- alternative ways of understanding- alternative approaches to treatment

• CAMs – possible place?

Diagnosis• based on ICD-10 (WHO) and DSM-IV (APA) criteria

• mood disorders – depression anxiety

• psychotic disorders

• crucial for access to treatment

NICE guidelines• Depression – mild to moderate; severe• Anxiety – + panic disorder, OCD & BDD • Self-harm• Eating disorders• PTSD• Bipolar disorder• Schizophrenia• Personality disorders – antisocial; ‘dangerous and severe’;

borderline • Plus guidelines on specific treatments

Schizophrenia - symptoms

Positive symptoms• Hallucinations – voices, things seen, etc.• Delusions – being controlled by outside

force; paranoia; thought insertion; thoughts being heard; magic powers

• Lack of insight• Increased salience (dopamine)

Schizophrenia - symptoms

Negative symptoms

• Self neglect

• Lack of emotional response

• Absence of thoughts

• Apathy

Schizophrenia - treatments

• Medication – ‘antipsychotics’

• Talking treatments – CBT

• Arts therapies – art, drama, music, dance

Medication

• Antipsychotics – neuroleptic; ataraxic[ataraxy – detachment; indifference – distinct from sedation]

• Block dopamine – and other neurotransmitters

Dopamine

Brain neurotransmitter

• Salience – the importance attached to thingsassociated with psychosis

• Voluntary movement

• Prolactin

• Effects on other neurotransmitters

synapse

• Photomicrograph of synapse

Synapse - diagram

Antipsychotics – adverse effects

• Parkinsonism

• Other movement disorders - tics, spasms, tardive dyskinesia, loss of fine control

• Akathisia

• Prolactin – breast development; lactationsexual side effects

• Heart effects – disturbances of heart rhythm

Antipsychotics – adverse effects

• Metabolic syndrome – weight gain, increased blood fats, diabetes

• Blood disorders

• Antimuscarinic effects

• Constipation

• Life-limiting

• ‘not worth the candle’?

Antipsychotics – and talking

• Reduce salience – hence some psychotic symptoms

• Do not change beliefs or past experiences

• need CBT or other talking therapy to unlearn things wrongly attributed and come to terms with damaging events (Human Givens therapy)

• Arts therapies – may help deal with bad memories; park difficult ideas.

Schizophrenia – controversies

• ‘a scientific delusion’ – subjective diagnosis

• An unhelpful label – stigmatising; implies deterioration

• No evidence for discrete condition

• 4% of population hear voices – only a minority are bothered by them

Alternative approaches• Formulation vs diagnosis (sense-making)• Other cultures • Hearing Voices Network – a new approach to

symptoms (the voices have a message – need to translate it)

• Narrative approaches (tree of life)• Group therapy – helps people know themselves

Recovery• Process rather than outcome

• Person rather than symptoms/diagnosis

• Hope

• The end of ‘untreatability’ (unheilbarkeit)

• Self-determination

• Allow people to tell their story

• Come off medication

• (‘hi-jacked by professionals’)

Medication withdrawal

• Psychoactive substances

• Consequences of long-term medication – receptor changes

• Abrupt withdrawal

• Slow withdrawal – dose reductionswitch to drug with longer half-life

Alternative therapies

• Help with adverse effects

• Help with withdrawal

• help with symptoms?

Acceptance as treatment

• Need for evidence of efficacy - scientific studies in peer-reviewed journals

Personalisation – an opportunity?

ResourcesBooks• Gail Hornstein – Agnes’s jacket• Marius Romme and Sandra Escher – Accepting voices• Jim Read – Psychiatric drugs: key issues and service user perspectives• South Somerset Mind – Art of recovery

Websites• www.mind.org.uk• www.hearing-voices.org• www.mentalhealth.org.uk• www.nice.org.uk