Recovery from psychosis : physical health, antipsychotic medication and the daily dilemmas for mental health nurses

This paper considers some of the dilemmas experienced by Mental Health Nurses everyday when faced with the seemingly conflicting relationships that exist between recovery, antipsychotics and the physical health of people experiencing psychosis. We examine the role of antipsychotics in the process of recovery from psychosis and argue that Mental Health Nursing’s laudable shift away from the medical model towards the concept of self-defined personal recovery should not result in overlooking the importance of physical health and medication management. Mental Health Nurses have a responsibility to help services users make an informed choice about treatment; this exchange of information should be based on the best available evidence rather than philosophical values or personal opinion

Medication management training for mental health professionals: a programme of research

Aim This research programme aimed to investigate issues relating to the management of patient non-adherence with antipsychotic medication. The findings from the patient-related studies and the systematic literature review informed the development of a medication management staff training programme; which was evaluated in terms of the effects on mental health professionals’ understanding and clinical practice in Hong Kong. Background Medication management interventions which are designed to maximise the potential benefits of antipsychotic medication for severe mental illness have shown promise in improving symptoms, reducing relapse rates and addressing non-adherence. Subsequent medication management studies which involve training mental health professionals in similar psychosocial interventions have also demonstrated that improvements in mental health professionals’ knowledge, attitudes and skills can result in improved patient outcomes; however, the studies have not been replicated outside western general psychiatry settings and therefore the effects of training mental health professionals in other clinical contexts have not been established. Methods This research programme consists of a series of five studies that utilised a variety of methodological approaches. Three cross-sectional surveys were used to identify and explore clinical problems central to medication management in order to refine the staff training programme; the first investigates the extent of, and associations with, antipsychotic medication non-adherence in prisons. Qualitative interview data from the prison study provides additional context to the requirements for medication management training interventions by exploring prisoners’ experiences of taking antipsychotic medication. The second survey ascertains and explores the problem of non-adherence with antipsychotics in an Asian population, and the third provides an estimate of potential treatment-related physical health problems. A systematic literature review investigates studies which measure the effects of medication management training on clinicians’ knowledge, attitudes and skills. Finally concept mapping and clinicians’ narratives are used in a longitudinal case series 2 study in order to establish the transferability of medication management training to an Asian setting and evaluate the effects of training on clinicians’ understanding and clinical practice. Results Patients’ positive attitudes towards antipsychotic medication, particularly awareness of the need for treatment predicted higher levels of adherence, and concerns about the adverse effects of these medications are closely related to the environmental context of treatment. Concerns associated with antipsychotic side effects appear to be less prominent when patients are not working or in prison but they may influence adherence when demands on functioning change. The modified medication management training was effective in improving clinicians’ understanding and was felt to be transferrable to an Asian setting, but patients’ and families’ traditional cultural beliefs about mental illness and concerns about the effects of western medication on physical health were found to be particular challenges when implementing adherence interventions. Patients with severe mental illness in Hong Kong are twice as likely compared to the general population to have developed metabolic syndrome, consequently medication management interventions could require greater focus on the identification and management of physical health problems; which may help to address patient and family concerns about long-term treatment. The staff training programme requires psychopharmacology teaching, provision of clinical supervision and side effects management content in order to improve clinicians’ confidence when implementing medication management interventions. Conclusions Concerns about the adverse effects of treatment that influence adherence are environmentally bound. As influences on medication adherence are different in different settings, staff training programmes should place more emphasis on the local context in order to improve efficacy and the feasibility of implementation. The results suggest that in Hong Kong medication management interventions should have an increased focus on families and that treatment satisfaction could be a suitable target for interventions. The findings also present a question about whether previous medication management studies have given due consideration to predicting and managing concerns about the impact of side effects on functioning over the longer term and the potential effects of medication on patients’ physical well-being. The outcomes of this programme also demonstrate that future medication management training studies need to use robust study designs in order to more certainly attribute clinicians’ improvements to the training intervention and could consider measuring treatment satisfaction as a primary patient outcome measure

The effects of training mental health practitioners in medication management to address nonadherence: a systematic review of clinician-related outcomes

Background: Nonadherence with medicine prescribed for mental health is a common problem that results in poor clinical outcomes for service users. Studies that provide medication management-related training for the mental health workforce have demonstrated that improvements in the knowledge, attitudes, and skills of staff can help to address nonadherence. This systematic review aims to establish the effectiveness of these training interventions in terms of clinician-related outcomes. Methods: Five electronic databases were systematically searched: PubMed, CINAHL, Medline, PsycInfo, and Google Scholar. Studies were included if they were qualitative or quantitative in nature and were primarily designed to provide mental health clinicians with knowledge and interventions in order to improve service users’ experiences of taking psychotropic medications, and therefore potentially address nonadherence issues. Results: A total of five quantitative studies were included in the review. All studies reported improvements in clinicians’ knowledge, attitudes, and skills immediately following training. The largest effect sizes related to improvements in clinicians’ knowledge and attitudes towards nonadherence. Training interventions of longer duration resulted in the greatest knowledge- and skills-related effect sizes. Conclusion: The findings of this review indicate that training interventions are likely to improve clinician-related outcomes; however, due to the methodological limitations of the current evidence base, future research in this area should aim to conduct robust randomized controlled trials with follow-up and consider collecting qualitative data to explore clinicians’ experiences of using the approaches in clinical practice

Aducanumab for Alzheimer’s disease: the never‐ending story that nurses should know

In October 2019, the American pharmaceutical company Biogen stated intention to apply to the US Food and Drug Administration (FDA) for the candidate drug aducanumab to be licenced as a therapeutic agent for the treatment of Alzheimer's disease (AD). If approved, aducanumab would become the first new medication licenced specifically for the treatment of AD in the past decade; and approval in the US may be a precipitant for approval elsewhere

Antipsychotics in the treatment of psychosis: risks and benefits

Antipsychotics are important in the treatment and recovery of people with psychosis but current evidence suggests that mental health nurses are not always conversant with the risks and benefits of these drugs. This inadequate knowledge has important ramifications for the provision of safe and effective care. This article outlines the risks and benefit profiles associated with contemporary antipsychotic drugs to enhance mental health nurses' knowledge of medicines. Ultimately, comprehensive knowledge of medication, their actions, risk and benefits should promote mental health nurses' effectiveness in medicine

Oral liquid antipsychotic formulation in the treatment of psychosis

This article discusses oral liquid antipsychotics as a treatment option to either oral tablets or injection formulation. It discusses bioavailability, treatment in emergencies and the potential merits of using oral liquid preparations in terms of relevant practical issues

The prevalence of metabolic syndrome amongst patients with severe mental illness in the community in Hong Kong--a cross sectional study

Background: Patients with severe mental illness are at increased risk of developing metabolic disorders. The risk of metabolic syndrome in the Hong Kong general population is lower than that observed in western countries; however the prevalence of metabolic syndrome in patients with severe mental illness in Hong Kong is unknown. Method: This cross-sectional study aimed to estimate the prevalence of metabolic syndrome in patients with severe mental illness in Hong Kong and to identify the relationships between metabolic syndrome and socio-demographic, clinical and lifestyle factors. Results: A total of 139 patients with a diagnosis of severe mental illness participated in the study. The unadjusted prevalence of metabolic syndrome was 35%. The relative risk of metabolic syndrome in comparison with the general Hong Kong population was 2.008 (95% CI 1.59-2.53, p < 0.001). In a logistic regression model sleep disruption and being prescribed first generation antipsychotics were significantly associated with the syndrome, whilst eating less than 3 portions of fruit/vegetables per day and being married were weakly associated. Conclusion The results demonstrate that metabolic syndrome is highly prevalent and that physical health inequalities in patients with severe mental illness in Hong Kong are similar to those observed in western countries. The results provide sufficient evidence to support the need for intervention studies in this setting and reinforce the requirement to conduct regular physical health checks for all patients with severe mental illness

Physical fitness and activity levels among Chinese people with schizophrenia: A cross-sectional study with matched case-control comparison

People with schizophrenia have an increased risk of developing cardiometabolic diseases and a reduced life expectancy. Studies conducted mainly in Western settings report low amounts of activity and poor levels of fitness in this population. This study aims to compare physical fitness and activity levels between people with schizophrenia/healthy matched controls and investigate potential associations between these variables. A cross-sectional study was conducted with 57 community-dwelling people with schizophrenia and 57 age-, gender- and BMI-matched controls. Participants completed the International Physical Activity Questionnaire and the YMCA Fitness Assessment Protocol with accompanying cardiovascular/lung function tests. Cardiorespiratory fitness was significantly better in healthy matched controls than individuals with schizophrenia in all areas (all p<.05, d=0.38 to 1.06). Performance in best trunk flexion, half sit-ups and one-minute pulse recovery following the 3-minute step test were significantly worse in the schizophrenia group (all p<.001, d=0.76 to 1.04). Higher levels of weekly moderate activity (t=-2.66, p=.009) and total weekly activity levels (t=-2.013, p=.047) were reported by the healthy controls. Levels of vigorous activity were significantly correlated with some areas of lung functioning in the schizophrenia group (all p<.05). The findings show that Chinese people with schizophrenia have significantly poorer fitness than matched healthy controls, demonstrating the need to provide timely effective exercise-based interventions as a matter of routine to attenuate the risk of developing chronic physical illnesses

Predictors of subjective recovery from recent-onset psychosis in a developing country: a mixed-methods study

Purpose This study was conducted to: (a) investigate the levels and progress of subjective recovery from recent-onset psychosis; (b) examine its predictive factors and; (c) describe perceived challenges and opportunities affecting recovery. The findings were expected to help inform recovery-oriented psychiatric care in low-income, particularly African, countries. Methods This sequential explanatory mixed-methods study involved 263 service users with recent-onset psychosis from Northwestern Ethiopia. For the quantitative part, a 9-month longitudinal study approach was employed with three time point measurements over 9 months. Predictor variables for subjective recovery from recent-onset psychosis were identified by hierarchical multiple linear regression tests. Following the quantitative survey, individual qualitative interviews were conducted with 19 participants. Interview data were transcribed and thematically analysed. Results High mean subjective recovery scores were recorded throughout the study (Questionnaire about the Process of Recovery score ranging from 44.17 to 44.65). Quality of life, internalized stigma, disability, hopelessness, satisfaction with social support, and central obesity were significant predictors of subjective recovery across the three time points. Participants' perceived challenges and opportunities affecting their recovery were categorized into four themes. Conclusion In Ethiopia, a low percentage of individuals with SMIs initiate psychiatric treatment and many discontinue this to attend spiritual healing. In this study, the Ethiopian SMI patients engaged consistently in psychiatric treatment indicated high mean subjective recovery scores. Devising mechanisms to integrate the psychiatric treatment and spiritual healing sectors are suggested. Approaches to improve quality of life, functioning, hope, internalized stigma and provide need-based social support are suggested

An international multi-site, randomized controlled trial of a mindfulness-based psychoeducation group programme for people with schizophrenia

BackgroundWe aimed to test a mindfulness-based psycho-education group (MBPEG), versus conventional psycho-education group (CPEG) versus treatment-as-usual (TAU), in patients with schizophrenia-spectrum disorders over a 24-month follow-up.MethodsThis single-blind, multi-site, pragmatic randomized controlled trial was conducted in six community treatment facilities across three countries (Hong Kong, mainland China and Taiwan). Patients were randomly allocated to one of the treatment conditions, and underwent six months of treatment. The primary outcomes were changes in duration of rehospitalizations and mental state (PANSS) between baseline and one week, six, 12 and 18 months’ post treatment.ResultsA total of 300 patients in each country were assessed for eligibility between October 2013 and 30 April 2014,38 patients per country (n=342) were assigned to each treatment group and included in the intention-to-treat-analysis. There was a significant difference in the length of re-hospitalizations between the three groups over 24 months F (2,330) =5.23, p=0.005, with MBPEG participants having a shorter mean duration of re-hospitalizations than those in theother groups. The MBPEG and CPEG participants had significant differential changes in proportional ORs of complete remission (all individual PANSS item