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Therpeutic Interventions

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MO2 Therapeutic Interventions

A therapeutic intervention is an intervention or activity aimed at enhancing mental health through one of the following: improving the quality of mental health, reducing the negative effects of mentally ill health or distress, or retaining psychological/psychosocial equilibrium (Derwen NHS Trust, 2008).

This essay examines the therapeutic intervention of medication and the process of a patient changing to a new medication to hopefully improve the patient’s quality of life.

At my most recent placement, I have been working with a community mental health team that specialise in patients with enduring mental health problems. The majority of these patients have either schizophrenia or bi-polar disorder. I have discovered from this placement that the introduction of different therapeutic interventions to patients is a major part of the nurse’s role, especially in the community, this includes; suitable medications, social group therapies and other possible interventions that could be tried in conjunction with or instead of medication. Later in this essay I will discuss this in further detail.

I have decided to base my essay on a particular patient; a man aged 45 years old who has Schizophrenia and has been on a depot injection of Depixol (Flupenthixol Decanoate) for nearly 20 years, having been ill since the age of 17. This man has tried other medications throughout these years but Depixol in combination with Chlorpromazine (as per required need (PRN)) seems to be the only medication tried that reduces his auditory hallucinations andidiosyncratic beliefs to a manageable state and controls other symptoms of Schizophrenia, such as; hallucinations, delusions and bizarre behaviours (Strauss, Bowers and Keith, 1983).The central goals of antipsychotic medication in the long-term treatment phase are; continued suppression of the acute symptoms (continuation therapy) or prevention of the occurrence of another episode of acute symptoms (maintenance therapy) (Dixon, Lehman and Levine, 1995).

This patient currently experiences many extra-pyramidal side effects from being on Depixol. The British Medical Association and Royal Pharmaceutical Society of Great Britain (2008) and Long (2008) both state that Depixol is among the conventional antipsychotics that may cause a higher incidence of extra-pyramidal reactions. The National Institute for Clinical Excellence (NICE) (2002) recommend that people experiencing side effects with older antipsychotics should be offered an atypical antipsychotic. NICE advise that the oral atypical antipsychotic drugs amisulpride, olanzapine, quetiapine, risperidone and zotepine are considered as first choice treatments for schizophrenia, but Aripiprazole was not considered as part of this guideline as it was not approved until 2004.

This essay will monitor the transition from a fortnightly depot injection of Depixol (80mg) to the use of oral medication Abilify (Aripiprazole) (15mg once daily). It will also explore how this medication has an effect on this patient’s Schizophrenia.  In addition, I will study the role of the Community Psychiatric Nurse (CPN) and the community mental health team in supporting this patient.

Our community team will observe the transitional change of medication and monitor the effect of the new medication Abilify. This will be achieved by effective communication and various assessments on fortnightly home visits and telephone calls. I will perform a literature search to investigate the positive and possible negative effects of Abilify and compare with other antipsychotic medications. I will also research other therapeutic interventions including social and psychological methods.

People with Schizophrenia and other severe mental illness may require considerable support from health care professionals and in some cases over a long period of time. Treatment of Schizophrenia should be based on an understanding of each individual’s needs and make further psychological development possible through interactive relations (Alanen, 1997). People with Schizophrenia may experience persistent psychotic symptoms in addition to; considerable impairment in their ability to live independently, work and relate to others (Dixon, Lehman and Levine, 1995). Schizophrenia has affected this gentleman’s life in many ways; he constantly relies on support from his family, he is very socially isolated, he lacks motivation to do many ordinary daily tasks and requires prompts, he has not been employed since he first became psychotic at the age of 17 and has continuously experienced throughout these years auditory hallucinations andidiosyncratic beliefs which affect his daily functioning.

My community mental health team are involved in this particular patient’s care, this is because he has experienced enduring mental health problems for many years, which have been poorly controlled by medication. I believe the reasons why this gentleman needs support from a CPN are because: he is best at communicating when he is comfortable in his own home, sometimes he avoids seeking medical help and advice, he requires someone to detect his relapse signs, additionally his medication requires alteration from time to time. In general, CPNs have three main roles: Assessor, Therapist (administering medication, support, counselling, behavioural psychotherapy and family therapy), and also Liaison (an important link between primary and secondary care or social service departments) (Royal College of Psychiatrists, 1997).

My rationale for choice of medication as an intervention is that I have experience of many patients on various placements on Depixol depot injection, which is perceptibly a common drug but one of the older anti-psychotic medications. By looking at the process of a patient changing from older to newer antipsychotic medication, I feel I will witness either a good transition with positive effects on the mental health of this person, or a bad transition with negative effects on the mental health of this person, which may deter into a possible acute relapse. If this mental atrophy permeates, a transfer back to Depixol may be required. By following this intervention, whatever the result, I feel I will gain a good understanding of possible outcomes from a change of medication. Also I feel that my knowledge about the drug Abilify is very limited. Therefore by doing this essay I plan to extend my knowledge of this medication and then pass on this information to the patient.

When first reading this patients file I decided to form a timeline of past medications so that it would be simpler to assess his history (of over 20 years). There have been several tried and failed antipsychotics. These medications were either unsuccessful at controlling the auditory hallucinations, or had unmanageable side effects. One of the previously failed medications includes Risperidone. I believe this medication was selected because in clinical trials (British Medical Association and Royal Pharmaceutical Society of Great Britain, 2008) and treatment of this community team’s other patients Risperidone has worked well at decreasing the symptoms of schizophrenia. Unfortunately, Risperidone had very little effect at controlling this patient’s schizophrenia and therefore a return to Depixol was made to steady this gentleman’s mental health.

Typical and atypical antipsychotics do provide a treatment response for most people with schizophrenia, whether that is a reduction in psychotic episodes or a lessening in the severity of their illness. However, a proportion of people still do not respond adequately to any antipsychotic medication.

Before the development of atypical antipsychotics, treatment choice was restricted to conventional (or typical) antipsychotics. These are known to cause a range of side effects including extra-pyramidal symptoms (Travis, Burns, Dursun et al., 2005). Although atypical agents provide a favourable alternative (advocated by the NICE in the UK), they are also associated with side effects. These differ to typicals and usually include weight gain, sedation and hyperprolactinaemia (an increase in the hormone prolactin) (Travis, Burns, Dursun et al., 2005). Additionally, atypical and especially typical antipsychotics are associated with serious adverse side-effects which can often compromise compliance with medication and therefore increase the incidences of relapse (El-Sayeh and Morganti, 2006). According to Navratil (2008) older medications’ side-effects are particularly associated with unpleasant movement problems (extra-pyramidal symptoms) such as muscle spasms and stiffness, shaking and fidgeting. Patients may have to take additional medication to combat these movement disorders. Long term side effects may be more of a problem, particularly Tardive Dyskinesia (involuntary movements mainly of the mouth and face). My patient has reported that he experiences uncontrollable twitching and shaking of the hands and feet. Bhattacharjee and El-Sayeh (2008) said Abilify offers a more favourable adverse-effect profile, with significantly lesser risk of causing extra-pyramidal symptoms and other side effects compared to older conventional antipsychotics.

The reason we came to a decision of using Abilify over other atypical antipsychotics is that recent studies have shown that some antipsychotics (such as clozapine, olanzapine, risperidone and quetiapine) are associated with weight gain, elevated glucose and elevated triglycerides which compound the risk for coronary artery disease (Gupta, 2003) . Our patient is very self-conscious about his weight and we feel that weight gain could be a reason for non-adherence. Although early patient education including advising on healthy diet, exercise and smoking cessation may prevent weight gain and development of diabetes mellitus (Buse, 2002), but patient co-operation and determination is needed.

Education plays an important role in the successful treatment of a mental illness. NICE (2009) states that we must ask patients what they know, believe and understand about medicines before prescribing new treatments and when reviewing medicines. We must also accept that the patient has the right to decide not to take a medicine, even if we do not agree with this decision, as long as the patient has the capacity to make an informed decision. NICE (2002) states the choice of antipsychotic drug should be made mutually by the patient and the clinician responsible for treatment, based on an informed discussion of the relative benefits of the medications available and their common side-effects. Patients are more likely to adhere to treatment, if the care team involves them in the prescribing decision (Travis, Burns, Dursun et al., 2005). The common side effects of Abilify and the process we will follow to introduce a new medication into his bodily system have been discussed with the patient and his consent has been gained. He understands that the outcome may not necessarily be positive but he is willing to endeavour. Because he has lived with his mental illness for many years he is aware of signs of relapse and therefore would seek assistance early. We feel his family would also be in contact if they had any issues of concern.

From researching Depixol and Abilify I have discovered that the literature shows Depixol (Flupenthixol Decanoate) is a Thioxanthene, an older conventional (typical) antipsychotic medication that blocks the dopamine D2 receptors in the brain (Dixon, Lehman and Levine, 1995). Depixol can be given in tablet form or as a depot intramuscular injection. The usual dosage of a depot injection is between 50mg every 4 weeks to 300mg every 2 weeks.

Abilify (Aripiprazole) is being publicized as a new type of atypical antipsychotic, a quinolinone derivative which appears to affect both neuro-transmitters serotonin and dopamine; as a result it seems to have effects on a broader range of symptoms (Navratil, 2008). Aripiprazole was approved by NICE and became licensed for use in the European Union (EU) in June 2004 for the treatment of the mental illness Schizophrenia (moderate to severe) (Bristol-Myers Squibb, 2008, and Travis, Burns, Dursun et al., 2005). Abilify is available as a tablet, an orodispersable tablet and an oral solution. This patient will be prescribed ordinary tablet form at a dose of 15mg (once a day). The usual dosage is between 5mg and 30mg per day.

According to Sullivan, Bienroth, Jones et al. (2007) long term use of Abilify may result in real benefits for service users, as it has a favourable physical health profile compared to other drugs. Service users taking Aripiprazole may therefore be better able to take part in social activities, work, education and cognitive behavioural therapy, all of which would contribute significantly to their quality of life.

From my experience community nurses in particular have a large effect on influencing the consultant’s decision to prescribe specific medications for each patient, as the community teams generally have enhanced knowledge of their patients compared to the consultants, because they usually meet up with them much more often.

Before transition to Abilify this patient was on: Depixol 80mg (depot every 2 weeks), Procyclidine 5mg (3 times a day) and Chlorpromazine 50mg (PRN maximum 3 per day).

We will monitor this therapeutic intervention by using Liverpool University Neuroleptic Side Effects Rating Scale (LUNSERS). A LUNSERS assessment has been done previously on this patient and I have just recently completed another before discontinuing Depixol, I plan to repeat this assessment approximately 4 weeks after starting on Abilify 15mg and again after 8 weeks. Abilify should hopefully control the patients Schizophrenia equally or better that Depixol with fewer side effects, if this is not the case we may have to review the therapeutic intervention and consider other options. I have discussed this with the patient and he feels that if Abilify is unsuccessful he feels that returning to Depixol would be the best option to prevent acute relapse.

Abilify will be self-administered by the patient; there are no issues regarding his self-administration as he has been self-administering other medications throughout his history of mental illness. I have completed a medical Questionnaire with this patient to discover his view on why he takes his medication and what effects it has on him. From this I have discovered that this gentleman would continue to take his medication even without our support because he believes it keeps him well. He knows this from experience of failed medications and the trauma of when he became acutely mentally ill. I believe this man is very outspoken and would inform the team if he disliked the medication for any reason, he is not a person who does as he is advised and he usually requires persuasion to try new things.

 Although the patient will no longer require his depot injection, the community team will continue to visit once a fortnight to support and observe him through this medication change and until the team or patient feels our support and help is no longer needed. The Midland Therapeutic Review & Advisory Committee (MTRAC)(2004) recommend that Abilify treatment should be initiated and stabilised within secondary care for at least the first 6 months of the treatment, in order to monitor effectiveness and tolerability in individual patients.

The treatment is first delivered by reducing the Depixol to 40mg (half the usual dose) and introducing Abilify at 10mg (once a day). Then, the following week increasing Abilify to 15mg (once a day) with no further depot injections to be given. Bristol-Myers Squibb (2008) states clinical improvement from Abilify may take several days to some weeks and monitoring of the patient throughout this period is required.

After 2 weeks, when visiting him at home this patient expressed that he was feeling similar to before with occasional tolerable voices in the evenings, but fewer than before. No new side effects noticeable at this time and appearing somewhat more awake and energetic than he believes he was before. The literature to support this suggests that effects reported with Depixol include restlessness, insomnia, psychomotor agitation, headaches, drowsiness and somnolence (sleepiness) (Long, 2008). The drowsiness and somnolence greatly affected this man without him realising it.

Although the response to a single injection is usually aimed at lasting 2 weeks, it may stay in the system for 4 weeks or longer, particularly when higher doses are used or if a patient has been on a particular medication for many years.

After 4 weeks at my next home visit a LUNSERS assessment was completed that showed the current side effects he was now experiencing. I compared this to earlier LUNSERS assessments and discovered the amount of side effects had dramatically reduced. The only existing concern the patient had was that he had been experiencing terrible headaches. This is one of the possible side effects we identified from Abilify, I reassured him this was very common and encouraged him to continue. The patient stated he had been taking pain killers to treat the headaches and we advised him to continue to do this and if no change in a few days to contact our team. We were concerned that if the headaches continued the patient may want to discontinue Abilify without giving it a good chance to take effect. From clinical trials it has been discovered that anxiety, insomnia, and headaches are some of the most common side effects reported with Abilify, and headaches can occur in up to 30% of people but in most cases they are minor and either require no treatment or can easily be treated by themselves or a healthcare provider (Monson and Schoenstadt, 2009) . Other than this issue Abilify currently seems to be controlling the Schizophrenia as well as Depixol did previously.

After 6 weeks on our next visit he reported that the headaches discontinued after a total of 5 days and since this no other issues have occurred. His sleep has altered and he is now sleeping less (around 8 hours) and waking up on his own without an alarm. He reports that he has had no episodes of auditory hallucinations for several weeks now. Davis, Barter and Kane (1989) express that the expected time course of the improvement brought about by antipsychotic medications should occur within the first 6 weeks of treatment.

After 8 weeks Abilify is controlling the schizophrenia remarkably well and there are no noticeable side effects present. Some of the major side effects he was experiencing before while on Depixol, including twitching of the feet (which affected his driving) have now stopped and the patient reports he is feeling brilliant. His sleep pattern now seems very natural and no drowsiness present compared to before (when on Depixol).

During my time spent with this patient I have monitored this patient through a large and important transformation to his life. All healthcare professionals involved in this patient’s care have overseen a very successful therapeutic intervention introduced and are pleased with the present result. A big concern highlighted in this patient’s past care plans has been a lack of social inclusion due to no motivation and bad past experiences (of when he first became mentally ill) but now his motivation to venture out has increased, although he will still only socialise with members of his family this is a milestone he has partially overcome. He now looks forward to the future and everyone hopes this improvement will continue and improve his life to be as ”normal” as possible.

Interventions are not usually used singularly, in this case we have found a medication which controls the schizophrenia with no side effects and this has opened up new opportunities. Our Role as a community team has now changed, medication is great for tackling symptoms of mental illness but our role is now around social inclusion, engagement and relationship building. Promoting social inclusion is a major part of health promotion and many of our patients who have suffered with enduring mental health problems are socially isolated and reluctant to try new things. Mental Health Nursing is not just about getting the medication right and keeping the patient stable but it is about everything else as well.

Although antipsychotic drugs remain a treatment of choice for most patients, it is of interest to look at the effects of alternative therapeutic interventions, primarily methods focusing on psychosocial factors affecting schizophrenia. Malmberg and Fenton (2001) express that many alternative therapeutic interventions include psychoanalysis and this is considered to mean a method of eliciting from patients their past emotional experiences and their role in influencing their current mental wellbeing through talking therapy. These interventions include: Cognitive Behavioural Therapy, which changes problematic patterns of thinking or behaviour; Cognitive Analytical Therapy, which focuses on improving the client’s coping habits so future problems are easier to deal with; Dialectical Behaviour Therapy, which focuses on learning how to react normally to emotional triggers; Psychotherapy, which is based on the patient using their own insight to solve current problems; Family Intervention, which engages the family unit to work together as part of the therapeutic process; And Creative Therapy Groups (e.g. art, cooking or woodwork), to deal with emotional conflicts and promote social inclusion (Malmberg and Fenton, 2001). While being on this placement I have spent time with many of the local social inclusion therapy organisations to discover how their different therapy sessions impact on different people with mental health problems and also if any of these organisations would be suitable for my caseload as a community nurse is often the referrer. The reason why most of these are not suitable for this particular person despite efforts of persuasion to try is because he finds it difficult to form new relationships and does not like disclosing himself to others. He also avoids going to any new places or making changes to his daily structure.

When a patient is accepted onto a community mental health teams caseload they generally should have a personal recovery plan of some type either written or verbally discussed, of what they would like to achieve to get as close to “normality” as possible. The process of recovery is not just a case of becoming free of symptoms. Great emphasis is placed upon how to get on with life with or without symptoms (Perkins, 2002). Deegan (1997) describes recovery as a journey or a process, not a destination or a cure. Perkins (2002) goes on to say the challenge for people who experience mental health problems “is to rebuild a meaningful, satisfying and valued life”.

My findings emphasize the need to broadcast and implementexisting evidence-based therapies into routine clinical practiceand to identify new treatments including new medications with favourable risk-to-benefitprofiles to address mental health issues. Abilify was only licensed in 2004 so there are few clinical trials that have been undertaken on this medication as yet. By giving this medication over other suitable antipsychotics it has now impacted on my own, the community nurse and consultant’s opinion of the possible positive efficiency of this fairly new atypical drug on some schizophrenia patients. Due to this being one of the fairly new medications there is no scientific evidence to show the possible long-term effects of Abilify being used (for example over 10 years or longer). Abilify was licensed in the United States in 2002 (Travis, Burns, Dursun et al., 2005) so they have not performed any longitudinal studies as of yet either.

To encapsulate this assignment I believe I have identified the need of a CPN and the support they continue to give this patient. My understanding of the role of a community psychiatric nurse has now been amplified. This assignment has observed the introduction of a very successful therapeutic intervention (for the time being). I have discovered that currently there is a lot of positive literature (scientific, medical and non-medical) in support of using Abilify over other atypical antipsychotics and especially typical antipsychotics, but it does not differ greatly from typical or atypical antipsychotics with respect to treatment response, efficacy or tolerability. From this literature I have discovered that most of the visible side effects usually occur within the first few weeks of starting this drug and in most cases discontinue within 7 days. Throughout my literature search I have failed to find any negative issues around using Abilify, but perhaps in the future when more clinical tests have been performed new issues may be discovered. Furthermore, I have revealed that Abilify has a favourable side-effect profile compared to alternatives available, which may make it an appealing choice for patients with first onset of psychosis or other patients who have experienced problems with side effects while receiving other antipsychotic medications.

To conclude this essay I have enhanced my knowledge of different antipsychotic medications when comparing them to Abilify and I now believe I could now be more informative towards patients if they were to question me about antipsychotic medication. In addition, I have learnt about other therapeutic approaches and interventions available to patients and will continue to promote the use of these services throughout my nursing career.

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