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Management
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As with all patients suffering from a mental illness, management should be divided into assessment and treatment. At both stages psychological, physical, social factors should be considered.
Assessment
The initial assessment during the acute illness usually takes place in hospital and should include:
- Full history and mental state examination in particular identify delusions, hallucinations, thought disorder.
- Check for clouding of consciousness.
- Interview with an informant.
- Physical examination and appropriate investigations e.g. urine drug screen to exclude a drug induced psychosis, EEG to exclude temporal lobe epilepsy, brain imaging.
- Social assessment; housing, work, etc.
By the end of the assessment:
- Information supporting the diagnosis should have been collected.
- Particular risks the patient may present to themselves and others should have been identified.
- Vulnerability factors such as a family history of schizophrenia should have been considered.
- Possible precipitants to the acute illness should have been identified (why now ?).
- Factors which may maintain the illness or make relapse more likely should be explored such as high critical expressed emotion within the family or stresses at work.
- Decide whether the patient is prepared to accept treatment.
- Consider a differential or coexisting disorder such as:
- Drug induced psychosis, amphetamines, LSD.
- Alcoholic hallucinosis.
- Organic causes, acute confusional state, DT's, temporal lobe epilepsy.
- Affective psychosis, depression, hypomania.
Treatment
Physical.
The mainstay of treatment is pharmacotherapy. A group of drugs called the neuroleptics also known as major tranquillisers are used. The drugs that have been in longest use (the 'typical' antipsychotics/neuroleptics) block dopamine receptors and are classified according to their chemical structure. More recently a number of drugs have been introduced that act mostly on transmitter systems other than dopamine and are therefore termed 'atypical' antipsychotics/ neuroleptics.
Depot preparations administered every 2-4 weeks allow monitoring of patient compliance. They are usually given by a community psychiatric nurse which also has the advantage of close monitoring of the patient's mental state and anticipation and prevention of relapse.
Further discussion of this group of drugs is given in the pharmacotherapy handout.
Psychological Treatments.
These are aimed at support and reduction of stress. Family work with education about the illness may be particularly important when the family is hostile and critical towards the patient e.g. having unrealistic expectations of them. High critical expressed emotion is associated with an increased risk of relapse, particularly when the sufferer spends long periods at home with their family.
Social Rehabilitation.
Rehabilitation into work where relevant or attendance at a day centre. Balance between too much stress and under-stimulation with social withdrawal and apathy.
Where return home is not possible (e.g. rejected by the family) alternative accommodation may be sought in a hostel, group home or supportive lodging.
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