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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 things associated 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; lactation sexual 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 reduction switch 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? Resources Books • 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