Friday 6 December 2013

Quetiapine versus other atypical antipsychotic drugs for schizophrenia

Quetiapine is a second‐generation antipsychotic. Second‐generation or atypical antipsychotic drugs have become the mainstay of treatment in many countries for people with schizophrenia. They are called second‐generation drugs because they are newer than the older drugs, known as typical antipsychotics. Second‐generation drugs are thought to be better than the older drugs in reducing the symptoms of schizophrenia, such as hearing voices and seeing things, and are suggested to produce fewer side effects, such as sleepiness, weight gain, tremors and shaking. However, it is not clear how the various second‐ generation antipsychotic drugs differ from one other. The aim of this review therefore was to evaluate the effects of quetiapine compared with other second‐generation antipsychotic drugs for people with schizophrenia. The review included a total of 35 studies with 5971 people, which provided information on six comparisons (quetiapine vs the following: clozapine, olanzapine, risperidone, ziprasidone, paliperidone and aripiprazole). Comparisons with amisulpride, sertindole and zotepine do not exist, so more research is needed. A major limitation of all findings was the large number of people leaving studies and stopping quetiapine treatment (50.2% of people). The most important finding to note is that if a group is started on quetiapine, most will be off this drug within a few weeks (although the reasons for stopping quetiapine treatment are not covered by the review and so remain uncertain). Quetiapine may be slightly less effective than risperidone and olanzapine in reducing symptoms, and it may cause less weight gain and fewer side effects and associated problems (such as heart problems and diabetes) than olanzapine and paliperidone, but more than are seen with risperidone and ziprasidone. The limited information tends to suggest that people taking quetiapine may need to be hospitalised more frequently than those taking risperidone or olanzapine. This may lead to higher costs in some settings, but the information is not robust enough to guide managers.

Psychosocial interventions for people with both severe mental illness and substance misuse

‘Dual diagnosis’ is the term used to describe people who have a mental health problem and also have problems with drugs or alcohol. In some areas, over 50% of all those with mental health difficulties will have problems with drugs or alcohol. For people with mental illness, substance misuse often has a negative and damaging effect on the symptoms of their illness and the way their medication works. They may become aggressive or engage in activities that are illegal. Substance misuse can also increase risk of suicide, hepatitis C, HIV, relapse, incarceration and homelessness.

People who have substance misuse problems but no mental illness can be treated via a variety of psychosocial interventions. These include motivational interviewing, or MI, that looks at people’s motivation for change; cognitive behavioural therapy, or CBT, which helps people adapt their behaviour by improving coping strategies; a supportive approach similar to that pioneered by Alcoholics Anonymous; family psycho‐education observing the signs and effects of substance misuse; and group or individual skills training. However, using these interventions for people with dual diagnosis is more complex.

The aim of this review was to assess the effects of psychosocial interventions for substance reduction in people with a serious mental illness compared to care as usual or standard care. A search for studies was carried out in July 2012; 32 studies were included in the review with a total of 3165 people. These studies used a variety of different psychosocial interventions (including CBT, MI, skills training, integrated models of care). In the main, evidence was graded as low or very low quality and no study showed any great difference between psychosocial interventions and treatment as usual. There was no compelling evidence to support any one psychosocial treatment over another. However, differences in study designs made comparisons between studies problematic. Studies also had high numbers of people leaving early, differences in outcomes measured, and differing ways in which the psychosocial interventions were delivered. More large scale, high quality and better reported studies are required to address these shortcomings. This will better address whether psychosocial interventions are effective and good for people with mental illness and substance misuse problems.

Pimozide for schizophrenia or related psychoses

People with schizophrenia have ‘positive symptoms’ such as hearing voices and seeing things (hallucinations) and fixed strange beliefs (delusions). People with schizophrenia also have ‘negative symptoms’ such as tiredness, apathy and loss of emotion. Antipsychotic drugs are the main treatment for the symptoms of schizophrenia and can be grouped into older drugs (first generation or ‘typical’) and newer drugs (second generation or ‘atypical’). Pimozide is a ‘typical’ antipsychotic drug that was first introduced in the late 1960s and was given to people with schizophrenia. Pimozide is thought to be effective in treating the positive and negative symptoms of schizophrenia or similar mental health problems such as delusional disorder, but it produces serious side effects such as muscle stiffness, tremors and slow body movements. Pimozide may also cause heart problems and has been linked to sudden unexplained death. Monitoring the heart via electrocardiogram is now required before and during treatment with pimozide. It is well known that people with mental health problems suffer from physical illnesses such as heart disease and diabetes and can die on average twenty years younger than those in the general population.

An update search for this review was carried out 28 January 2013; the review now includes 32 studies that assess the effects of pimozide for people with schizophrenia or similar mental health problems. Pimozide was compared with other antipsychotic drugs, placebo (‘dummy’ treatment) or no treatment. Results suggest that pimozide is probably just as effective as other commonly used ‘typical’ antipsychotic drugs (for outcomes such as treating mental state, relapse, leaving the study early). No studies included delusional disorders, so no information is available on this group of people. No evidence was found to support the concern that pimozide causes heart problems (although this may be result of the fact that the studies were small and short term and the participants did not receive doses above recommended limits of 20 mg/d). Pimozide may cause less sleepiness than other typical antipsychotic drugs, but it may cause more tremors and uncontrollable shaking. The claim that pimozide is useful for treating people with negative symptoms also is not supported and proven. However, the quality of evidence in the main was low or very low quality, studies were small and of short duration and were poorly reported. Large‐scale, well‐conducted and well‐reported studies are required to assess the effectiveness of pimozide in the treatment of schizophrenia and other mental health problems such as delusional disorder.

Haloperidol versus placebo for schizophrenia

Haloperidol was first developed in the late 1950s. Research subsequently showed its therapeutic effects on the symptoms of schizophrenia, such as hearing voices and seeing things (hallucinations), having strange beliefs (delusions), aggressiveness, impulsiveness and states of excitement. This led to the introduction of haloperidol as one of the first antipsychotic drugs. Antipsychotic drugs are the main treatment for the symptoms of schizophrenia. Despite the introduction of newer antipsychotic drugs (second generation or ‘atypical’ drugs), haloperidol remains in widespread use and is the benchmark for judging the effectiveness of newer antipsychotic drugs.

The aim of this review was to evaluate the effects of haloperidol for schizophrenia and other similar serious mental illnesses compared with ‘dummy’ or no treatment (placebo). A new search for trials was carried out in May 2012 and the review now includes 25 studies with a total of 4651 people. Review authors rated the quality of evidence reported in the trials for seven main outcomes (global state, death, discharge from hospital, relapse, leaving the study early, adverse effects and satisfaction with treatment). For global state, leaving the study early and adverse effects the reviewers rated the evidence as moderate quality, however, relapse and discharge from hospital were rated to be very low quality evidence. There were no data available for death and satisfaction with treatment.

Based on moderate quality evidence, haloperidol was found to be better than placebo in treating schizophrenia. More people given haloperidol improved in the first six weeks of treatment than those given placebo. However, a significant number of people on haloperidol suffered from side effects, including muscle stiffness, uncontrollable shaking, tremors, sleepiness and restlessness.

Authors concluded that haloperidol is a potent and effective antipsychotic for treating the symptoms of schizophrenia but has the potential to cause debilitating side effects. People with schizophrenia and psychiatrists may wish to prescribe a newer antipsychotic drug with fewer side effects.

Finally, a large proportion of other information and data in the trials were poor and badly reported, meaning that better studies are required. Many people, from both groups left the trials early. This suggests that the design and running of the trials was poor and perhaps not acceptable to people. In light of these findings, it is perhaps surprising that haloperidol is a benchmark antipsychotic in widespread use for treating schizophrenia. It is also surprising that haloperidol is widely used as a comparison for new medication. Haloperidol is an effective antipsychotic drug but has serious and debilitating side effects.

Dance therapy for schizophrenia.

The first line of treatment of schizophrenia is usually antipsychotic drugs. Usually, these drugs are more effective in treating the 'positive symptoms' than 'negative symptoms' of schizophrenia. Moreover, antipsychotic drugs have debilitating side‐effects such as weight gain, shaking, tremors and muscle stiffness.

Dance therapy (also known as dance movement therapy, DMT) uses movement and dance to explore a person’s emotions in a non‐verbal way (without language or words). The therapist helps the individual to interpret their dance and movement and link them with people’s personal feelings. Dance has been used as a healing ritual since earliest human history, but the establishment of dance therapy as a profession is quite recent. Dance therapy can be used with people of all ages, races and genders. It can be effective in the treatment of people with medical, social, developmental, physical and psychological impairments. The review included one study with 45 participants. The aim was to compare dance therapy with standard care or other interventions. The one included study compared dance therapy plus routine care with routine care alone. In the main, there was no difference between those who engaged in dance therapy versus those who did not (for outcomes such as satisfaction with care, mental state, leaving the study early, quality of life). However, those who engaged in dance therapy showed significant improvement in negative symptoms.

Overall, because of the small number of participants, the findings are limited. There is little evidence to support or refute the use of dance therapy. Larger studies and trials are needed that focus on important outcomes (such as rates of relapse, quality of life, admission to hospital, leaving the study early, cost of care and satisfaction with treatment). Further research would help clarify whether dance therapy is an effective and holistic treatment for people with schizophrenia, especially in terms of helping people cope with negative symptoms that do not respond so well to antipsychotic drugs.

Quetiapine versus typical antipsychotic drugs for schizophrenia.

Antipsychotic drugs are the main treatment for schizophrenia, helping to treat both the positive symptoms (such as hearing voices, seeing things and having strange beliefs) and negative symptoms (including apathy, tiredness and loss of emotion) of this illness. Selecting the most effective antipsychotic drug that can be tolerated by people with schizophrenia is crucial to successful treatment. Older drugs (also known as typical or first generation antipsychotic drugs), such as chlorpromazine and haloperidol, have been used in treating schizophrenia for over 50 years. Although these older drugs are good at treating the positive symptoms of schizophrenia they tend to cause undesirable side effects. These side effects can mean that people do not tolerate or like taking these drugs, which may lead to relapse and admission to hospital. Since 1988, a newer generation of antipsychotic drugs has become available. These new drugs (known as atypical or second generation antipsychotic drugs) are effective in treating the symptoms of schizophrenia but thought to have less side effects than older drugs. However, although newer drugs may cause less side effects such as movement disorders, they have been linked to other side effects like heart problems or weight gain. Quetiapine is a new antipsychotic drug for schizophrenia that has been available for over a decade. However, it is not clear how the effects of quetiapine differ from older antipsychotic drugs. This review evaluated the effectiveness and tolerability of quetiapine versus older antipsychotic drugs. The review included 43 trials with a total of 7217 people. Most studies were from China. In the main, quetiapine did not differ from older drugs for the treatment of positive symptoms of mental illness. There were also no clear differences in terms of the treatment of negative symptoms. However, it is important to note that evidence from these trials suggests quetiapine causes fewer side effects (such as weight gain, dizziness, movement disorders, the inability to sit still, shaking, tremors and abnormal levels of the hormone prolactin, which can contribute to sexual and mental health problems). However, evidence from the trials is limited due to high numbers of people leaving early in almost all of the studies. More evidence through the completion of well designed studies comparing quetiapine with older antipsychotic drugs is needed.

Collaborative care approaches for people with severe mental illness.

Collaborative care aims to improve the physical and mental health of people with severe mental illness (SMI). Common to all definitions is that collaborative care aims to develop closer working relationships between primary care (family doctors or GPs and practice nurses) and specialist health care (such as Community Mental Health Teams). There are different ways in which this can be achieved, making collaborative care very complex. Integrating or joining‐up primary care and mental health services, so that they work better together, is intended to increase communication and joint working between health professionals (e.g. GPs, psychiatrists, nurses, pharmacists, psychologists). This is meant to provide a person with severe mental illness with better care, based in the community, which is often a less stigmatised setting than hospital, and that promotion of good practice helps consumers maintain contact with services. A major issue is that many GPs still feel that physical health problems (such as diabetes, heart disease, smoking cessation) are more their concern and see treatment of severe mental illness as the job of psychiatrists and other mental health professionals. Collaborative care aims to improve overall quality of care by ensuring that healthcare professionals work together, trying to meet the physical and mental health needs of people. The aim of the review was to assess the effectiveness of collaborative care in comparison to standard or usual care. An electronic search for trials was carried out in April 2011. The primary focus of interest was admissions to hospital. According to the one included study in this review, collaborative care may be effective in reducing going into hospital (less psychiatric admissions and other admissions). It also helps improve people’s quality of life and mental health. However, all evidence was either low or very low quality and further research is needed to determine whether collaborative care is good for people with SMI in terms of clinical outcomes or helping people feel better as well as its cost effectiveness.

Thursday 14 November 2013

Patient‐held clinical information for people with psychotic illnesses

User‐held information is where the ill person holds personal information about their care. Such records are becoming the norm in many settings and are becoming more popular with patients. This is especially the case where the person concerned is not in hospital and receives care from more than one professional. Providing people with information about their care is thought to increase their feelings of involvement in their treatment and aims to increase people’s satisfaction and participation with services, ensure early treatment and prevent hospital admission.

The value of user‐held personal information for those with severe mental illnesses is not known however and research evaluating the effectiveness is rare. Some research suggests that while many people decline the offer of a user‐held record, the majority of those who carry their records report this to be useful.

Based on a search in 2011, this review includes four trials with a total of 607 people and evaluates the effects of user‐held information for people with severe mental illness. In the main, the number of relevant studies is low, with poor reporting of some outcomes. Based on moderate quality evidence, the review found that user‐held information did not decrease hospital admissions, and did not decrease compulsory admissions or encourage people with severe mental illness to attend appointments (when compared to treatment as usual). Other important outcomes, such as satisfaction with care, costs and effect on mental health, were not available due to the limited quality of the four studies. There is therefore a gap in knowledge and evidence regarding user‐held information for people with severe mental health problems. Further evidence is also required on the different types of user‐held information (for example, if it involves the mental health team and what type of information is included in the record). Large‐scale, well‐conducted and well‐reported studies are required to assess the effects of user‐held information for people with mental illness. Two important randomised studies are currently taking place. For the present, despite a gap in evidence, user‐held information is low cost and acceptable to patients, so its use is likely to grow. However, it cannot be assumed that user‐held information is of benefit to people and is cost‐effective without further large‐scale, well‐conducted and well‐reported trials.

Haloperidol dose for the acute phase of schizophrenia

Schizophrenia is a mental illness where the person often experiences both positive symptoms (such as hearing voices, seeing things and having strange beliefs) and negative symptoms (such as tiredness, apathy and loss of emotion). Antipsychotic drugs are used to treat schizophrenia. The antipsychotic drug, haloperidol, is one of the most frequently used drugs worldwide for people with schizophrenia.

The benefits of antipsychotic drugs, such as haloperidol, need to be weighed against their tendency for causing debilitating side effects (such as movement disorders, weight gain, lack of drive) and in some cases an increased likelihood of physical illnesses such as diabetes and heart disease. These debilitating side effects may mean that people stop taking their medication, which can lead to relapse and going into hospital. It is, therefore, important to find a tolerable and effective dose of haloperidol, which helps control the symptoms of schizophrenia but with fewer side effects.

The main aim of this review was to determine the best range of doses of haloperidol for the treatment of schizophrenia. Nineteen trials were included that compared varying doses of haloperidol. Despite over 30 years of trials, data on the effects of differing doses of haloperidol are sparse and poorly reported. This is especially so for the lower dose ranges generally used for the treatment of schizophrenia today. However, lower doses of haloperidol may be just as effective as higher doses but result in fewer side effects. This review also suggests that an important bias against haloperidol may exist in modern trials comparing new drugs with haloperidol. Results are not conclusive and are based on small, short studies of limited quality.

The authors of the review note that it would be understandable if psychiatrists were cautious about prescribing doses above 7.5 mg a day and if people with schizophrenia did not want to take higher dosages. Further research is needed to assess the tolerability and effectiveness of lower doses. Low doses of haloperidol may be just as good as higher doses, but with fewer side effects.

Atypical antipsychotic medications for adolescents with psychosis

Schizophrenia and other serious mental illnesses often begin in adolescence, and treatment of adolescents with psychosis usually involves use of antipsychotic drugs. Newer drugs (atypical antipsychotics) are more popular than older ones (typical antipsychotics). However, this determination is based on the generalisation of adult treatment to a younger age group, with evidence from studies on adults generally guiding the treatment of adolescents. Adolescents may respond differently to medication compared with adults. This review looks at evidence derived from trials in which the participants are adolescents receiving atypical or typical antipsychotics or a placebo (dummy treatment) and/or high or low doses of medication. A total of 13 trials consisting of 1112 people between 13 and 18 years of age are included. Most studies were short‐term trials (completed within 12 weeks). In the main, no convincing evidence shows that newer drugs (atypical antipsychotics) are better than older ones (typical antipsychotics) in terms of their ability to treat the symptoms of psychosis. However, newer drugs may be more acceptable for young people to take because they produce fewer side effects in the short term. Furthermore, very little evidence is available to support the superiority of one atypical antipsychotic over another atypical antipsychotic. The nature of side effects also differs markedly between medications. For example, treatment with olanzapine, risperidone and clozapine is associated with weight gain, but aripiprazole is not associated with weight gain. Some evidence indicates that adolescents respond better to standard‐dose as opposed to lower‐dose risperidone. However, for aripiprazole and ziprasidone, a lower dose and a standard dose may be equally effective. Longer, clearer and more detailed research trials that use systematic ways of reporting and comparing the side effects of different antipsychotic drugs are much needed. So too is a research focus on other important outcomes such as hospital admission, service use, costs, behaviour change and possible improvements in people’s thinking. Until such research is completed, very little evidence suggests that newer drugs (atypical antipsychotics) are better than older drugs (typical antipsychotics) for the treatment of adolescents with schizophrenia.

Thursday 26 September 2013

Oral fluphenazine versus placebo for schizophrenia

Antipsychotic drugs are the first line and mainstay of treatment for schizophrenia. They help to effectively treat psychotic symptoms such as hearing voices and seeing things (hallucinations) and having strange beliefs (delusions). Fluphenazine was one of the first antipsychotics and has been available for around 50 years. Fluphenazine is inexpensive and in developing countries, may be one of the only drug treatments available. In most of Europe and North America, despite still being available, the arrival of newer antipsychotic drugs has reduced the use of fluphenazine and its market share. Fluphenazine has debilitating side effects, including: dizziness; movement disorders such as involuntary movements or spasms; shaking and tremors; inner restlessness and the inability to sit still; and problems with blood pressure, fever and muscle stiffness.

This review included seven studies and compared the effects of fluphenazine taken by mouth with placebo (‘dummy’ treatment). In the main, the findings of the review support the widespread view that fluphenazine is a potent and effective antipsychotic but has considerable side effects, other antipsychotic drugs may well be preferable. Fluphenazine is an imperfect treatment with serious side effects, so other inexpensive antipsychotic drugs with fewer side effects may be better for people with schizophrenia. Despite this, fluphenazine has a low cost and is widely available, so is likely to remain one of the most widely used treatments for schizophrenia worldwide. However, some of fluphenazine's side effects could be expensive in terms of human suffering and personal cost of treatment. Even though fluphenazine has been used as an antipsychotic drug for decades, there are still a surprisingly small number of well-conducted studies measuring its effectiveness and potential to cause side effects. Future large-scale research should report on important outcomes such as improvement in mental health, relapse, hospital discharge and admission, levels of satisfaction with treatment and quality of life.

Monday 9 September 2013

Interventions to encourage cancer screening uptake in severe mental illness.

Cancer is a leading cause of death worldwide, accounting for approximately 13% of all deaths in 2007. Some studies have reported an increased incidence of cancer in people with mental health problems. The Schizophrenia Commission reports that people with schizophrenia who develop cancer are three times more likely to die than those in the general population with cancer.

Mental illness is associated with certain health problems, including: obesity; smoking; drinking alcohol; and poor diet, all of which increase risk of cancer. It has been estimated that approximately one‐third of cancer deaths could be prevented with early detection, of which cancer screening is the most effective method. However, people with mental illness are less likely than others to take up available cancer screening. Reasons for non‐uptake include: low income; increasing age; lack of transport; embarrassment; lack of reminders; and lack of familiar care providers.

In the general population, telephone invitations, telephone counselling, prompts following the initial invitation and opportunistic screening are good at increasing uptake of cancer screening. Reducing financial barriers (i.e. providing free screening tests, bus passes or postage) may also help. GPs have also been offered incentives under the Quality and Outcomes Framework to provide regular physical health checks to people with mental illness. People with mental illness may require more individualised care, such as more intense counselling, to encourage screening.

A comprehensive search showed that currently there is no trial evidence for any method of encouraging uptake of cancer screening for people with mental illness. No specific approach can therefore be recommended. Early detection of cancer through screening is effective in improving patient outcomes, including death. Given that people with mental illness are at greater risk of cancer but less likely than others to take up available screening, better approaches that encourage uptake of cancer screening are needed urgently. Further research is required to ensure that people with mental illness do not miss out on cancer screening.

From a service user perspective (SUPER), it has been found that people with mental illness die on average 20 years younger than the general population, often from preventable diseases (such as cancer, heart disease and diabetes). Rethink Mental Illness is campaigning to ensure that the physical health needs of people with mental health problems are not neglected and calling for physical health champions.

Of chief concern is ‘diagnostic overshadowing’. This is where a diagnosis of mental illness overshadows and makes invisible any physical health problems. There is a need for health professionals, especially in primary care and GP surgeries, to be more aware of the physical health problems of people with mental illness. Mental illness is associated with certain health problems, including: obesity or being overweight; smoking; drinking alcohol; and poor diet, all of which increase risk of cancer. These unhealthy behaviours can often be prevented by GPs and nurses in primary care with information and advice about stopping smoking, eating a healthier diet and the need to take regular exercise. However, these behaviour changes are often very difficult for people with mental illness, so more intense and individual care is required for people to make and maintain a healthier lifestyle.


Monday 5 August 2013

Intermittent drug techniques for schizophrenia

Antipsychotic medication is the main treatment for schizophrenia and helps people cope with positive symptoms such as hearing voices, seeing things and having strange beliefs. However, long-term exposure to these drugs has been associated with serious side effects, such as: weight gain; uncontrollable shaking of the head, body or hands; tremors; muscle stiffness; difficulties with walking and balance; sleepiness or apathy; and even death. Some people stop taking their medication as these side effects limit people’s quality of life. Not taking medication can be a contributory factor that leads to relapse and hospitalisation. Against this backdrop, there is cause to consider the role of intermittently administering antipsychotic medication compared to the continuous use of antipsychotic medication.


Read the full summary here: http://summaries.cochrane.org/CD006196/intermittent-drug-techniques-for-schizophrenia


From a service user perspective (SUPER), the review notes that the landscape of psychiatric care has transformed dramatically over the past 50 years. There is an increased emphasis placed on a person-centred approach, where people with mental health issues are increasingly treated in outpatient or community settings and have more of a say in what treatment they would prefer. People with mental health issues who are prescribed drug treatment are now more likely to also receive psychological/ supportive therapy.

There is an increasing dialogue between psychiatrists and people with mental health issues about pathways of treatment.

There is also a growing and grassroots based recovery movement, where psychological, counselling and peer support activities help people in their journey toward rehabilitation outside the confines of psychiatry and traditional antipsychotic medication. Often, these new recovery activities are run by people who have experienced mental illness, for people experiencing mental health problems and with people collectively, making it a more holistic and personalised form of treatment.

For example, see:
http://www.intervoiceonline.org/
http://www.workingtorecovery.co.uk/
http://rufusmay.com/
http://www.peter-lehmann-publishing.com/
http://www.runciman.dk/The_harmful_concept_of_schizophrenia.pdf

Friday 14 June 2013

Treatments to help prevent psychosis in women who have just given birth.

There is a small percentage of women for whom giving birth leads to psychosis. Postnatal psychosis affects one to two in every 1000 new mothers and is almost always a mood disorder accompanied by loss of contact with reality, hearing voices and seeing things (hallucinations), having strange beliefs (delusions), severe thought disturbance, and abnormal behaviour. It can be a life-threatening condition with an abrupt onset within a month of childbirth.

Read the full summary here: http://summaries.cochrane.org/CD009991/treatments-to-help-prevent-psychosis-in-women-who-have-just-given-birth

From a service user perspective (SUPER), it is surprising that there is so little research on women’s mental health just after childbirth, particularly as postnatal psychosis is potentially life- threatening.  There is risk of suicide, child neglect and abuse and even in some extreme cases killing the child.  News coverage has highlighted the devastating story of a mother with severe postnatal depression who smothered her 10-day-old son after her medication was taken away (Steven Morris, The Guardian, Friday 12th November, See: http://www.guardian.co.uk/uk/2010/nov/12/mother-smothered-baby-son-court).  Recent news has also centred on a pregnant mother who killed her three children before committing suicide (http://www.dailymail.co.uk/news/article-2309426/Lowestoft-deaths-Father-Craig-McLelland-pays-tribute-3-children-killed-pregnant-mother-Fiona-Anderson.html).  This makes the prevention of postnatal psychosis even more urgent and important.

Tuesday 7 May 2013

Benzodiazepines alone or in combination with antipsychotic drugs for acute psychosis.

People with mental health problems may exhibit agitated, violent and aggressive behaviour which can be a danger to themselves or others. Usually, de-escalation techniques such as talking to the patient are used to calm down the situation. However, people’s behaviour may be too disturbed, violent or agitated. In these circumstances, rapid tranquillisation is given to achieve a state of calm. Three major classes of drugs are used to achieve rapid tranquillisation: typical antipsychotics; benzodiazepines; and more recently atypical antipsychotics.

Read the full summary here: http://summaries.cochrane.org/CD003079/benzodiazepines-alone-or-in-combination-with-antipsychotic-drugs-for-acute-psychosis

From a service user perspective (SUPER), having a mental health problem can be an experience that is frightening, agitating and even terrifying.  Hearing voices and seeing things can make people feel scared and panic, so that they become agitated.  A person I knew in hospital often saw people covered in snakes, while another saw people on fire.  I myself have heard frightening and taunting voices, saying: “You wait until you see what I’m going to do to you!”.

Being agitated and panicking is therefore a common experience for people with mental health problems.  Sometimes tranquillisers and sedatives are requested by people with mental health problems to calm down. 

However, people can become aggressive and violent.  This sometimes leads to people being restrained and injected with drugs to calm them down.  On one occasion I witnessed, both restraint and injecting tranquilisers were used because a girl was trying to cut her wrists with the shards of a broken bottle.  Another time a patient was about to hit a nurse.

Sometimes, though, health staff can jump in precipitously and too quickly to restrain and tranquilise people.  I have witnessed on several occasions people being forced to the floor, spread- eagled and injected with sedatives. 

Health staff need to get to know the person, so that they can talk to them and understand the ‘triggers’ or signs that show that someone is about to become violent or aggressive.  Communication, one-to-one conversations and getting to know the patient are not only valuable therapeutically for recovery, but allow the nurse and person with mental health problems to anticipate and stop the ‘triggers’ of aggressive and violent behaviour.  De- escalation techniques involve communication and talking, giving the person with mental health problems undivided attention so that they feel valued.  It is necessary to focus on people’s feelings and be non- judgemental, develop a plan together to manage behaviour as well as using positive talk about people’s problems.

Tuesday 2 April 2013

Nidotherapy for schizophrenia.

Nidotherapy (from the Latin ‘nidus’ or ‘nest’) aims at identifying the need for and making changes to a person’s environment and surroundings. It works alongside other treatments to make improvements to a person’s well being, housing, money management, personal relationships, work and other factors. The aim of nidotherapy is not to change the person (whereas other psychological therapies often aim to make changes in an individual’s behaviour, emotions and thinking) but to create a better ‘fit’ between the environment and the individual.

Read the full summary here: http://summaries.cochrane.org/CD009929/nidotherapy-for-schizophrenia

From a service user perspective (SUPER), nidotherapy seems an intriguing, exciting but experimental approach to helping people with mental health problems.  Unlike other psychological therapies which focus on changing an individual’s behaviour, emotions and thinking, nidotherapy seeks to make changes in a person’s environment and surroundings.  Nidotherapy works alongside other treatments to make improvements to a person’s well being, housing, money management, personal relationships, work and other factors.  By focusing on the individual’s environment, rather than the individual themselves, this new therapy might be less stigmatising and more holistic than other psychological approaches that centre around the problems with an individual’s behaviour, emotions and thinking.  Nidotherapy seeks to make people’s social networks and relationships stronger, more harmonious and with a better ‘fit’.  Nidotherapy is new and at an experimental stage, so further information on its benefits and possible hazards is much needed before it can become more mainstream and accepted in health services.

Friday 8 March 2013

Training to recognise the early signs of recurrence in schizophrenia.

Training in early warning signs techniques encourages people to learn, detect and recognise the early warning signs of future illness. Studies indicate that noticing even small changes in signs and symptoms of schizophrenia can often predict future illness and relapse two to 10 weeks later.

Read the full summary here: http://summaries.cochrane.org/CD005147/training-to-recognise-the-early-signs-of-recurrence-in-schizophrenia

From a service user perspective (SUPER), training in recognising early warning signs of illness and relapse seems like a good idea.  Training helps people with mental health problems, health professionals, families and carers to anticipate future illness.  This is preventative, helping people to avoid relapse and admission to hospital.  But it is also a collaborative endeavour, leading to personal insight about illness and self- understanding, so giving people with mental health problems more ownership, a greater say and more power to build their own recovery.

At the opposite end of the spectrum, the authors of the review note that it is possible that training in recognising early warning signs might have difficulties and negatives.  For example, there might be increased depression due to an increased self-focus.  Awareness of illness has also been linked to suicidal thoughts.  Another negative effect might be increased medication due to the increased reporting of people’s symptoms, without reducing relapse.

However, on balance, training and keeping a personal logbook, reflective diary or folder would seem to offer people more insight, control and say in their care.

Aripiprazole versus other atypical antipsychotics for schizophrenia.

This review includes 12 research trials with 6389 people. It evaluates whether aripiprazole is better than other drugs.

Read the full summary here: http://summaries.cochrane.org/CD006569/aripiprazole-versus-other-atypical-antipsychotics-for-schizophrenia

From a service user perspective (SUPER), it is perhaps surprising that there is so little information on the different medications that are available to service users (atypical antipsychotics such as aripiprazole, olanzapine, risperidone and ziprasidone).  The wholesale use of these drugs is widespread, but the benefits as well as the negative side- effects for service users are not fully understood or adequately researched.  Although these medications are thought to help service users, people with mental health issues may have little understanding of the medications that they are taking and little say in which ones they would prefer in their treatment. 

The first line of defence should certainly include medication, but service users should also have a greater say in what medications they would prefer.  Research should not just focus on the effectiveness of these medications, but should look at subjective and personal factors, which is just another way of saying that service users should have more say in the tablets or drugs they take in their treatment.  Taking into account the views of service users and carers, patient preference and impact on quality of life are mentioned by this review as needing further research.  This would encourage people to take their medication, so making it better understood, fair and acceptable for people.

It has also been found that antipsychotic drugs work better and are more acceptable to people when combined with psychological therapies: the ‘talking cures’ of psychotherapy; family therapy; counselling; and cognitive behavioural therapy.  Both objective factors (the effectiveness of medication) and subjective feelings (what treatment or therapy service users say they feel they would prefer) need to be taken into consideration, so as to strike a good balance in the treatment, care and possible recovery of people who use mental health services.