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 CareSelf-managementMotivational interviewingRelapse 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 self-

responsibility 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 dynamicEnforced treatment - clinician takes

responsibility, impedes recoveryVs

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 yrsWith 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 Evidence-base

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 self-responsibility, establishing meaningful relationships

Recovery – the Evidence-base

What people with severe mental illness want… Support to -Live in their own homeWorkHave a reasonable incomeHave 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 Dischargeto GP for People in Recovery

Many studies of outcome following transfer back to Primary Care -Mental health and level of function

outcomes equalPhysical health status improvedPatient/family satisfaction greaterGP satisfaction high if -

Access to training for the roleReady 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 conditionself-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 usual dose range Risperidone 1-6 mg Olanzapine 2.5-20 mg Quetiapine 100-900 mg* Aripiprazole 5-30 mg

* Useful sedative/anxiolytic at 25-75 mg

New Generation Antipsychotics

Benefits –Equal antipsychotic effect to older drugsBetter at reducing mood symptoms and

cognitive impairmentsAlso reduce negative symptoms (poor

motivation, social withdrawal, poor self-care, blunted affect etc)

New Generation Antipsychotics

Side Effects:Generally better tolerated than older

antipsychoticsDon’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