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 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 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 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 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 Medicationusual dose range  Risperidone1-6 mg  Olanzapine mg  Quetiapine mg*  Aripiprazole5-30 mg * Useful sedative/anxiolytic at 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 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