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Managing Chronic Mental Illness in Primary Care The “recovery” model of managing serious mental illness Prognosis for Recovery Tools and frameworks for promoting recovery in Primary Care Self-management Motivational interviewing Relapse prevention plans/”advance directives” Modern Antipsychotic medications What is Recovery As defined by consumers “Having a life worth living” “Living well in the presence or absence of symptoms of mental ill-health” As defined by a leading expert in recovery-oriented MHS: “Living in stable accommodation, paying taxes, and having a social life” What is the “Recovery” Model Equivalent for MHS of the “Self-Management” model of chronic care management in Primary Care (e.g., Flinders model) Optimal clinical care is a necessary but not sufficient condition of recovery – Recovery as a personal journey, taking selfresponsibility central to this process Critical place of hope and positive expectation of the future (cf, past “therapeutic nihilism” re chronic mental illnesses such as schizophrenia) Clinician Role in Recovery Ongoing provision of education and information Fostering hope Encouraging self-responsibility Working collaboratively: “You need medication to stop hearing voices” vs “You want to work, you say voices interfere with work, medication may help make this manageable so you can work” Clinician Role in Recovery Understanding “insight” in a MH context: NOT a one-dimensional concept as traditionally taught – “lack of insight” in psychiatry, vs. “denial as a helpful strategy” in medicine Adjustment to psychosis as a serious illness, occurs over time as with any illness “Forced” insight can actually precipitate suicidal thinking/behaviour – being “overwhelmed” by insight Clinician Role in Recovery Recovery – the power dynamic Enforced treatment - clinician takes responsibility, impedes recovery Vs The right to learn from mistakes – being supported through a process of stopping medication, and learning from the consequences of this – shared responsibility, facilitates recovery Psychotic Illness Prognosis Vermont Longitudinal Study: Followed patients discharged from a US state mental hospital for up to 30 yrs With time, most made substantial degrees of recovery – lived independently, worked etc. Challenged the prevailing notion of chronicity/incompetence of patients with psychotic illnesses Recovery – the Evidencebase Largely qualitative research: Being supported to live in own home gives better outcome than “residential rehab” placements Being supported to maintain employment reduces service utilisation by up to 2/3 Recovery narratives – common themes of regaining hope, having “someone care and believe in you”, being supported to regain selfresponsibility, establishing meaningful relationships Recovery – the Evidencebase What people with severe mental illness want… Support to Live in their own home Work Have a reasonable income Have social relationships… …in other words the same as everyone else Key Services for Recovery Support-type relationship(s) within which trust can build, understanding of “what will make a difference” be built, and based on this care be co-ordinated Supported housing Supported employment Good collaborative clinical care Outcome from Discharge to GP for People in Recovery Many studies of outcome following transfer back to Primary Care Mental health and level of function outcomes equal Physical health status improved Patient/family satisfaction greater GP satisfaction high if Access to training for the role Ready access to specialist support/advice Tools for Ongoing Primary Care Use Relapse prevention plans: Recognising the “relapse signature” – typical earliest signs of impending relapse - to allow earliest possible intervention Developing a shared plan that recognises and responds to this (see handout for example) Often useful to have a clear “advance directive” allowing the person to influence care in the case of a significant relapse (eg, preferred/most effective medications, best setting for care, use of mental health act if that has been helpful etc.) Tools for Ongoing Primary Care Use Fostering Self Management – ongoing education re the condition, support to develop a sense of control over the condition self-care strategies (sleep, diet etc.) self-help strategies (exercise, activity scheduling etc) encouragement with medication adherence Tools for Ongoing Primary Care Use Motivational Interviewing – useful as part of fostering good “self management” as with any chronic health condition New Generation Antipsychotics Medication Risperidone Olanzapine Quetiapine Aripiprazole usual dose range 1-6 mg 2.5-20 mg 100-900 mg* 5-30 mg * Useful sedative/anxiolytic at 25-75 mg New Generation Antipsychotics Benefits – Equal antipsychotic effect to older drugs Better at reducing mood symptoms and cognitive impairments Also reduce negative symptoms (poor motivation, social withdrawal, poor self-care, blunted affect etc) New Generation Antipsychotics Side Effects: Generally better tolerated than older antipsychotics Don’t cause prominent EPSE (NB – Risperidone CAN sometimes cause EPSE esp at higher doses) DO cause set of metabolic changes – “Metabolic Syndrome” – weight gain, hypercholersterolaemia, impaired glucose metabolism – Olanzapine worst, Aripiprazole best in this regard Metabolic Syndrome Is the major issue in the long-term drug treatment of psychotic illness One of major causes of average 15-20 yrs lower life expectancy of psych patients Manage as for this syndrome in any patient Early identification Review medication options Promote lifestyle changes – diet, exercise, smoking Treat as indicated …Recognising challenges of this with this popn