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 12^th 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.

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.

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.

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.

Flupenthixol versus placebo for schizophrenia.

Flupenthixol is an antipsychotic drug, first made available in the UK in 1965. Although this drug has been available for many years, few systematic reviews of its effectiveness are available and the effects of this drug in helping people cope with the symptoms of schizophrenia are not currently well measured, quantified and known.

Read the full summary here: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0049715/

From a service user perspective (SUPER), it may at first appear quite shocking that the use of flupenthixol is more rooted in the clinical experience and the everyday decision making of psychiatrists instead of being based on firm scientific knowledge.  This is often the case, though.  In my and other service users’ experience, we often progress through different medications until one is found that helps in coping with symptoms such as hearing voices and which lead to feelings of better stability. 

Side- effects from medication are nearly always a problem, with feelings of sleepiness, weight gain, restlessness, and shaking hands.  But the dosage of medication can always be reduced over time.  Newer drugs with less side- effects can be introduced by talking openly with a psychiatrist about your feelings and difficulties with side- effects.       

It has also been found that medication works better when combined with more person- centred care, such as psychotherapy, counselling, cognitive behavioural therapy, hearing voices and stress management groups, creative writing, music and art therapy. 

Benjamin Gray

Service User Expert

Rethink Mental Illness.  

Haloperidol as a means of calming people who are aggressive or agitated due to psychosis.

Haloperidol is a drug that can be taken as by mouth or injected. As well as being an antipsychotic (preventing psychosis), it calms people down or helps them to sleep.

Read the full summary here: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0049743/

From a service user perspective (SUPER), the experience of hearing voices, being agitated and seeing things can be confusing, frightening and sometimes terrifying.  If people’s voices are shouting at them, putting them down, being derogatory or abusive, then it is perhaps not surprising that people become aggressive and sometimes violent.  After all, if someone shouted at you in the street, many people would just shout back!  This is what it is like for people who hear voices or see things: it is like someone shouting straight into your ear and never going away. 

Many people choose to shout back at their goading voices and this can be taken as being aggressive and violent.  No one can hear the voice, the verbal abuse or what the voice is saying, so an aggressive response to hearing an internal voice can seem to come from nowhere.  A service user that I met some time ago would often walk along the hospital corridors, screaming back at her voices.  She would sometimes hit herself violently on the head, as if trying to physically knock the voices out of her mind.  This was seen as aggression and unexplained violence by onlookers, but left me with mixed feelings of pity, consternation and fear.  

Similarly, three other people who I met in hospital would often hear voices that seemed to come from the television.  This would make them frightened and aggressive.  On one occasion, this led to the television being smashed and the individual being forcibly injected with tranquillisers to calm him down.  

Unfortunately, some people may become very aggressive or violent towards others.  They may have panic attacks or be in emotional turmoil.  Sometimes sedatives and tranquillisers are necessary to help people calm down (and some people even ask for them to help them cope). 

The use of these sedatives is never ideal, and the use of forced injection can feel like a violation.  It can break the trust between the person with mental health problems and nurses.  Nurses want to foster and build therapeutic relationships with people.  But all the time it takes to build up feelings of trust and intimacy can be broken in an instant, when force is used to restrain or inject the person.

I was unfortunate enough to witness the injection of sedatives on two other occasions: the first time involving a young girl called ‘B’ who was trying to cut herself with the shards of a broken bottle; and the second time a man called ‘R’ who was violently kicking the door of the nurse station and shouting abuse at staff.  The use of sedatives in these two situations could perhaps be said to be necessary but never ideal or therapeutic in the long term.

Often, all it takes is for a nurse or member of staff to ‘de-escalate’ the situation.  This involves nurses talking to the individual, to calm them down before they become agitated or aggressive.  Other techniques, such as seclusion, can often give people some space and time to calm down in their own room. 

Benjamin Gray

Service User and Service User Expert

Rethink Mental Illness