Guidelines for Managing Mental Disorders

 Guidelines for Managing Mental Disorders

The first step towards making a diagnosis is to ask the patient what is wrong. Then a full history of the presenting condition and other relevant facts should be taken. After this, a general and detailed medical examination with specific focus on the presenting symptoms should be carried out. Patients present with or complain about certain symptoms. These are subjective reports. The mental health worker carries out a medical examination to identify signs related to an illness or the presenting symptoms. The findings from this examination are objective.

 

The general physical examination consists of:

 

• Basic observations, such as the person’s walk, skin tone, voice intonation and ability to hold a normal conversation.
• Taking the blood pressure and checking for basic signs of disease such as anaemia or swelling of the legs.
• Examining the various organ systems of the body; the heart, lungs, bowels, etc. For a person with a psychiatric disorder, it is also important that a neurological examination is performed. This examination gives an understanding of the wellbeing of the person’s brain, mental function, nerves and muscles. It is the tool that mental health workers use to identify structural and psychiatric abnormality.
• A psychiatric examination is also performed to determine the individual’s mental condition. This involves investigating the individual’s abilities regarding orientation, attention span, concentration and memory. Any psychopathology must also be identified, for example abnormalities in perception of stimuli, thought content, speed of thoughts and logical thinking. Using all of the available evidence, the mental health worker is then able to make a diagnosis.
• From a list of the possible diagnoses based on the symptoms and signs, the mental health worker identifies the most likely cause, and rules out other diagnoses. The mental health worker will consider both psychiatric conditions and physical diseases.

 

Treatment

 

The treatment of mental disorders includes various forms of psychotherapy, psychiatric medication (biomedical treatment), and other practices (Gazzaniga and Heatherton, 2006). A major option for many mental disorders is psychotherapy.

 

Psychotherapy

Psychotherapy is an interpersonal intervention, usually provided by a mental health professional that employs any of a range of specific psychological principles and techniques. This therapy applies psychological principles and techniques to treatment of a psychological disorder. Psychotherapy includes discussion of the psychological problem and specific exercises/techniques that are designed to help a client function better in everyday life. Psychotherapy is a learning process in which mental health professionals seek to help individuals who have mental disorders and mental health problems. It is a process that is accomplished largely by the exchange of verbal communication; hence it often is referred to as “talk therapy.”

Participants in psychotherapy can vary in age from the very young to the very old, and problems can vary from mental health problems to disabling and catastrophic mental disorders. Although people often are seen individually, psychotherapy also can be done with couples, families, and groups. In each case, participants present their problems and then work with the psychotherapist to develop a more effective means of understanding and handling their problems. Psychotherapy is effective for selected individuals with some mood disorders, anxiety disorders, schizophrenia, personality disorders, and for mental health problems seen in somatic illness.

There are several main types. Cognitive behavioral therapy (CBT) is used for a wide variety of disorders, based on modifying the patterns of thought and behavior associated with a particular disorder. There are various kinds of CBT therapy, and offshoots such as Dialectical Behavior Therapy. Psychoanalysis, addressing underlying psychic conflicts and defenses, has been a dominant school of psychotherapy and is still in use. Systemic Therapy or Family therapy is sometimes used, addressing a network of relationships as well as an individual themselves. Some psychotherapies are based on a humanistic approach. Some therapies are for a specific disorder only, for example interpersonal and social rhythm therapy.

Biomedical Treatment

Mental disorders are treatable, contrary to what many think. An armamentarium of efficacious treatments is available to ameliorate symptoms. In fact, for most mental disorders, there is generally not just one but a range of treatments of proven efficacy. Most treatments fall under two general categories, psychosocial and pharmacological. Moreover, the combination of the two—known as multimodal therapy—can sometimes be even more effective than each individually.

The past two decades have seen an outpouring of new drugs introduced for the treatment of mental disorders (Nemeroff, 1998). New medications for the treatment of depression and schizophrenia are among the achievements stoked by research advances in both neuroscience and molecular biology. Through the process known as rational drug design, researchers have become increasingly sophisticated at designing drugs by manipulating their chemical structures. Their goal is to create more effective therapeutic agents, with fewer side effects, exquisitely targeted to correct the biochemical alterations that accompany mental disorders.

Biological Treatment is the term used when physiological methods are used to treat mental disorders. There are however different conventional names of drug groups used in the treatment of mental disorders. Despite the different conventional names of the drug groups, there can be considerable overlap in the kinds of disorders for which they are actually indicated. There may also be off-label use. There can be problems with adverse effects and adherence.

 

Psychiatric medication is also widely used to treat mental disorders. These are licensed psychoactive drugs usually prescribed by a health worker (medical practitioner and clinical officer). Medications have been developed to treat many psychological disorders. Generally, these medications work by altering neurochemical systems in the brain. There are several main groups and these include:

 

• Antidepressants are used for the treatment of clinical depression and to manage agitated or hostile behaviour related to depression as well as often for anxiety and other disorders. This group of medications is used to treat people who are severely depressed. Most antidepressants will restrain the metabolism of serotonin and/or norepinephrine. Such drugs are called Selective Serotonin Reuptake Inhibitors (SSRI), and they actively attempt to prevent the aforementioned neurotransmitters from dropping to the levels at which depression is experienced. SSRIs will often take 3-5 weeks to have a noticeable effect, due to the inability of the brain to process the flood of serotonin and it reacts by down regulating the sensitivity of the auto receptors, which can take up to 5 weeks. Currently, Bi-functional SSRIs are being researched, which will occupy the autoreceptors, bypassing the 'throttling' of serotonin. Another type of antidepressant is a Monoamine Oxidase Inhibitor, which are thought to block the actions of MAO, an enzyme which assists in the breakdown of serotonin and norepinephrine. MAOI's are typically only used in the event that a tricyclic antidepressant or SSRI fails to prevent or exacerbates depression.

 

a.     Monoamine Oxidase inhibitors (MAOIs) — this class of antidepressants is used infrequently because people have to adhere to a strict diet or the drug can cause a toxic reaction. (e.g. isocarboxazid , phenelzine) and tranylcypromine.

b.     Tricyclic antidepressants (TCAs)—This class is more effective than MAOIs, with fewer side effects. Alcohol should not be used in conjunction with this medication (e.g clomipramine, imipramine and amitriptyline).

c.      Selective serotonin reuptake inhibitors (SSRIs) are also are used to treat panic disorders (e.g fluvoxamine, citalopram (paroxetine); also used for panic disorder, fluoxetine and sertraline).

 

• Anxiolytics or Tranquilizers are used for anxiety disorders and related problems such as insomnia. Common drugs used today are usually benzodiazepines. These drugs produce an immediate calming effect for a person who may be experiencing anxiety. Patients can become dependent on these drugs. The most common drugs are: diazepam, lorazepam, nitrazepam and chlordiazepoxide.

·     Mood stabilizers are used primarily in bipolar disorder, mainly targeting mania rather than depression. The most common drugs are: lithium, lamotrigine and carbamazepine.

·     Antipsychotics are used for psychotic disorders, notably in schizophrenia. Neuroleptics (antipsychotics)—this class of drugs helps to reduce serious symptoms (e.g., hallucinations, delusions, paranoia) of schizophrenia in particular. These medications are moderately successfully in reducing hallucinations and similar serious expressions of altered behaviour. Essentially, these drugs act as dopamine blockers. The most common first generation drugs are: haloperidol, trifluoperazine, chlorpromazine and thioridazine.

 

Significant Adverse Effects of Psychiatric Drugs (Only common side effects are noted. Prescribers should check the medication literature for all potential side effects and drug interactions)

 

Medications just like food produce both beneficial effects and side effects. People are highly

variable in regard to how much benefit they will get from a drug and the type and severity of the side effects they will experience. While side effects usually are evident soon after starting to take the medication, the desired effect may not be seen for several weeks, and may take months of continuous use before the maximum benefit is evident. Some side effects, especially those that appear early, are temporary and may go away or become less severe after a few weeks. Most side effects are related to drug dose; the higher the dose, the worse the side effect. Resistance to taking prescribed medications is often due to unpleasant side effects. It is important that the prescribing mental health worker discuss this with the patient and seek the most effective and acceptable plan for treatment.  In order to understand the side effects of drugs used in the treatment of mental disorders, we are going to present them under the four classes as follows:

 

Antipsychotics

 

Some significant side effects of this group of drugs are:

 

• Allergic reactions. If these occur, it is usually in the first two months of treatment. If any of the following occur during this time, a health worker must be notified: rash, fever, sore throat, stomach pain, vomiting, and diarrhoea.
• Autonomic reactions. These side effects include dizziness or fainting when first sitting or standing, dry mouth, blurred vision, difficulty in urinating, constipation. They may decrease or disappear with time.
• Drowsiness. This can be troublesome at first, but tends to decrease or disappear after a few weeks.
• Extra pyramidal reactions (movement problems). These include akathisia (restlessness, pacing, rocking, foot tapping), dystonia (muscle spasms; usually in the first few days of treatment), and pseudo parkinsonism (muscle stiffness, tremor, shuffling gait, slow movement, or drooling). They may be treated by reducing the dose of antipsychotic drugs, or by adding drugs such as Artane trihexyphenidyl) or Cogentin (benztropine).
• Tardive dyskinesia. This syndrome sometimes occurs after long term use of antipsychotic drugs. It includes involuntary movements such as tongue protrusion, lip smacking, chewing movements, grimacing or frowning. It may also involve the extremities (finger twitching, arm movements) or other muscle groups in the body. Early signs should be reported to the mental health worker because, unless the drug is changed or the dose reduced, the symptoms may get worse and/or become irreversible.

 

Mood stabilizers

 

Lithium requires checking for blood levels at intervals to regulate the dose so it will control symptoms with the fewest side effects. Some side effects may be nausea, vomiting, diarrhoea, abdominal cramps, muscle weakness or tremor, thirst, frequent urination, tiredness or sleepiness, weight gain. If muscle spasms, dizziness, or convulsions occur and the patient may have to stop taking the medication until after review.

 

 

Antidepressants

 

Side effects of tricyclic antidepressants can include autonomic reactions, stomach upset, weight gain, drowsiness, nightmares, inability to sleep, sexual dysfunction, or increased seizure activity for people with a seizure disorder. Side effects of Monoamine Oxidase Inhibitors may include ringing in the ears, sexual dysfunction, or weight gain. Some serious reactions such as hypertensive crisis, rapid heart rate, and chest pain may result when MAOIs are given with certain foods and drugs.

 

Anxiolytic agents

 

Side effects can include dizziness, drowsiness, loss of muscle coordination, blurred vision, agitation, weight gain, diarrhoea.

 

Treatment of Mental disorders

 

Ideally mental disorders are best managed when therapy is combined. The combined use of medication and psychotherapy is a common approach to treating psychological disorders (Sammons and Schmidt, 2001). But where it is not possible to combine , especially in an outpatient setting , and where pharmacotherapy is considered in the treatment of a person living with mental disorder, careful selection of essential psychotropic medicines is a prerequisite (WHO, 2002). Selecting a limited number of essential psychotropic medicines is economical and entails fewer risks of duplication, confusion and mistakes. Essential medicines used ought to be selected on the basis of consensus between experts as to which medicines should be available in health care systems. This is what in charges ought to discuss with practitioners managing mental disorders.

 

Prescribers, dispensers and consumers are more easily able to remember therapeutic effects and adverse reactions, and do not have to cope with too many different dosage regimes and confusing nomenclature. Furthermore, careful selection facilitates bulk purchase and easier management of medicines (storage and distribution). It also allows for a more rational and efficient approach to training in prescribing and dispensing. Because of its considerable impact on the quality of care and the cost of treatment, a carefully considered selection of medicines is one of the most cost-effective means of improving mental health services. For example, evidence shows that newer psychotropics may have some advantages, but they are not always more effective, and usually much more expensive.

 

WHO has a Model List of Essential Drugs, including psychotropics, which has been updated on a bi-annual basis for the past 25 years. Medicines are specified by international non-proprietary name (INN), or generic name, without reference to any brand name or specific manufacturer (WHO, 1997). In the 2002 and 2003 updates of the WHO Model List, medicines have been selected by defining treatment guidelines on the basis of available evidence of effectiveness (e.g. information from the Cochrane collaboration; see www.cochrane.org). Based on these guidelines, the essential medicines needed for treatments have been defined. The 2003 update of the WHO Model List of Essential Medicines (WHO, 2003) includes nine medicines for the satisfactory management of mental disorders and eight anticonvulsants/anti-epileptics.

 

Box 1. Psychotherapeutic drugs on the WHO Model List of Essential Drugs

• Drugs used in psychotic disorders chlorpromazine tab, 100mg; syr, 25mg /5ml; inj, 25mg /ml in 2-ml amp; fluphenazine inj, 25mg (decanoate or enantate) in 1-ml amp; haloperidol tab, 2mg, 5mg; inj, 5mg in 1-ml amp.
• Drugs used in mood disorders : (i) Drugs used in depressive disorders; amitriptyline tab, 25mg (hydrochloride) (ii) Drugs used in bipolar disorders carbamazepine scored tab, 100mg, 200mg lithium carbonate caps or tab, 300mg, valproic acid enteric coated tab, 200mg, 500mg (sodium salt).
• Drugs used in generalized anxiety and sleep disorders: diazepam scored tab, 2mg, 5mg.
• Drugs used in obsessive-compulsive disorders and panic attacks: clomipramine caps, 10mg, 25mg (hydrochloride).

 

Anticonvulsants/antiepileptics: carbamazepine scored tab, 100 mg, 200 mg, clonazepam scored tab 500 micrograms, diazepam inj, 5 mg/ml in 2-ml amp (intravenous or rectal), ethosuximide caps, 250 mg; syr, 250 mg/5ml, magnesium sulfate inj, 500 mg/ml in 2-ml amp; 500mg/ml in 10-ml amp, phenobarbital tab, 15-100 mg; elixir, 15 mg/5ml, phenytoin caps or tab, 25 mg, 50 mg, 100 mg (sodium salt);inj, 50 mg/ml in 5-ml vial (sodium salt)valproic acid enteric coated tab, 200 mg, 500 mg (sodium salt) Source: WHO (2003).

 

The process by which psychotropic medicines are selected is of critical importance. In Zambia where these drugs are not available in outpatient departments and health centres, when initiating integrative care, the process should be consultative and transparent, with explicit selection criteria, and published application procedures. It should also be linked to evidence-based treatment guidelines. A standing committee at district level should be appointed that includes people from different fields, such as medicine, nursing, clinical pharmacology, pharmacy and public health, as well as health workers at the grassroots level. The participation of representatives of consumers’ and patients’ organizations like The Mental Health User of Zambia is highly recommended.

 

Decision-making may be difficult when more expensive medicines have some advantages, as is the case with some new antidepressant medicines which have similar efficacy and milder side-effects, but higher costs as compared to older antidepressant medicines (WHO, 2001). In such cases, it is important to calculate the cost of overall treatment, as this may actually be lower for medicines that are more expensive on a tablet-to-tablet (dose-to-dose) basis. The use of simple indicators, such as cost per month of therapy or cost per hospital admission prevented, may also be useful.

 

Individualised Treatment Plans

 

People living with a mental disorder may be treated by a group of mental health practitioners or by one practitioner. However in either case, effort should be made that all patients have individualised treatment. In most countries, there is provision in laws that authorises a mental health worker to be responsible for preparing, reviewing on a regular basis and revising as required the treatment plan for each patient. The plan in most cases should be authorised and signed by the authorised psychiatrist.

 

An initial treatment plan should be prepared as soon as practicable following a diagnosis or an admission. In practice, all members of the treating team will have a role in contributing to and implementing a treatment plan. The extent to which each mental health worker is involved will depend on the clinical setting and local practice. The mental health worker who has the greatest involvement with the patient, such as the case manager and as delegated by the in charge of a facility, should take a lead role in coordinating the contributions of team members.

 

Content of treatment plans

 

A treatment plan must outline the treatment the patient is to receive. It should include a brief, clear statement of the treatment objectives and strategies and be easily understandable by all involved, in particular the patient and any nominated carers. It must be based on a current assessment of the patient’s needs and any identified risk factors. Assessments should consider psychiatric symptoms and medical and physical needs. Risk factors, drug and alcohol, social, accommodation, family (including parenting) and personal

issues should also be considered, although not all need to be commented on—the treatment plan should only reflect current priorities for the patient and the treating team.

 

There should be capacity to record the patient’s own treatment goals, their views about the plan and any actions to deal with conflicts. A treatment plan should specify what the team will do to address each identified need, state who is responsible for each identified action and expected outcomes. The treatment objectives for each identified need must be realistic, focused on recovery and achievable within the expected timeframe of the plan.