The orthodoxy puts high EE [ times of continuing High Emotional Expression ] in the famly context. Really it has a wider application -where there is pressure on a vulnerable patient, to resolve an issue, but with no solution in hand to relieve that pressure i.e. unresolving anxiety - one of the drawbacks from the illness, at summoning together sucess, in how to face up to, deal with and handle difficult choices.
Professionals see medication, not necessarily as curing or improving, but as preventing a worse illness i.e. keeping the illness at its best level, but for those where that is not a much better position, at least protecting those without much benefit, from the effects of situations of ongoing high EE - anxieties - which would otherwise lead to breakdown, into the illness controlling the life, with consequences for the person and for others.
Professionals do not seem to realise that they are in an authoritaive position which they should be using to declare that helping patients into an aftercare posirion of interest which keeps going in a routine way, is an aftercare Continuing Health Treatment issue. If they do not exercise that authority, in not insisting on that prospect for long-term patients , by registering it as a health UNMET NEED for this illness, they are abandoning patients to their own debilitated resources, and inevitable failure.
Professional services must recognise their part in that failure.
A fight they cannot win in the face of competition for funding.The necessities for the illness are medication, which will be acceptable in the situation that patients find themselves, if it brings with it, in consequence, the second consideration, a better life.
If it does not then why take continuous medication. for the sake of appeasing society which ignores, denies, or stigmatises them ?
The November issue of the psychiatric House magazine [ British Journal of Psychiatry ]
is devoted to an evaluation of the current state of knowledge about the depot delivery of medications used for treating schizophrenia.Australia has the longest practical experience
In urban Melbourne, 13% of patients with schizophrenia were subject to a Community Treatment Order [ CTO ]. This is consistent with the findings of others for this region.
This rate doubled over the subsequent 4 years, so that by 2002 a quarter of patients with schizophrenia were on CTOs.
This occurred in the final phase of transition from a traditional hospital-based service delivery system to a more community-based system, with a small number of short-term acute psychiatric beds. Despite a changing balance in the type of antipsychotics prescribed, the association between CTOs and Long Acting Injections [ LAIs ] remained strong throughout the study. By 2002 just under half of those on CTOs were also prescribed an LAI.
In essence, as a proportion of all antipsychotic-treated patients at each time point, the rate of patients subject to a CTO with an LAI remained relatively stable over time.
In 1998, of the patients receiving a CTO, three-quarters were prescribed an LAI,
but in 2002, of those receiving a CTO only slightly less than half were prescribed an LAI. Thus, there was a reduction in the proportion of patients on CTOs who were also prescribed an LAI, but it still remained relatively high. It is likely that LAI prescribing is, in the main, a clinician response to poor adherence
and that the CTO is the mechanism used to compel reluctant patients to take the injection.Two main aspects regarding use of an LAI with a CTO include the changing treatment patterns for schizophrenia and the nature of psychiatric service provision.'
The practice with depot medication follows the accepted experience
that relapse frequently follows discontinuing the medication that was previously successfulNo coincidence that it comes along with the first year of practice with Community Treatment Orders.
No surprise that the CTO's are used most in the management of schizophrenia in the community.
They are more likely to forget their medication, and more likely to damage their reputation – and that of the management of the illness in general – than the other serious mental conditions.The Orders are a comfort to those professionals who are alarmed and ashamed of the media exposures about the lapses in service, around and before, subsequent homicides, that should have been prevented .
Depot regimes are used principally where oral medication has been tested and been found to be efficacious,
but not proved to be effective because it was often forgotten to be taken,
or just abandoned, when those with some residual illness were less able to be engaged and supervised.,
and were not helped into a routine to follow which they could accept,It has to be said that it is still not clear how and where the medications work .
It is agreed that reducing the firing up of D2 receptors by the neuro-transmitter agent dopamine is the mechanism for efficacy,
but that the efficiency of achieving this at the site of the striatum in the mid-brain cannot be the whole story
because relapse does not always occur when the level of D2 receptor occupancy there, falls below what has previously been seen as the effective level [ ~ 60% ]. The Striatum is also an intermediate on the way to Parkinsonism states – an unwanted side -effects- of many depot medications – which is more likely to follow greater than 80% Striatal occupancy.Depot medication has to follow the individual's experience with the oral equivalent medication, so that the type of medication introduced, the dosage and the frequency of the injections can be estimated and their introduction monitored correctly.
What has been sadly missing,and is still missing despite these compendium of papers describing experience, is sufficient usage of monitoring of blood levels, in depot regimes.
There has been a general acceptance that there is a lowest level below which efficacy is likely lost; but not a generalisable level which would be the optimum for all to reach.
The individual variations in the dosages to reach such a level varied so much.
The best helpful fact about the depot regimes would have been the blood level for the particular person,
just before the next injection was due, at a time when the regime had previously been shown to be a successful one: usually in the longer admission stays in the old hospitals.That could still be done in the low and medium secure units, and the Secure hospitals, before the release back into local admission units or into the community service.
Then there would be an easy check on the depot effect by taking the blood level before an injection was due, and expecting it to be in the range found in the hospital stay.I can't remember the article but thee was one paper which reported that blood levels before an injection were often found to be absent or lower than the efficacy level.
Carers were best placed to see the behaviour going along with this,
the illness behaviour being seen – not reportable by patients - just before an injection was due
– importantly for a community carer to know about in their 'handling' of what ever problems that might have come up then.
The other fact noticeable to carers [ and patients ] was that the seeping of medication into the blood stream was not a flat one.
More could be delivered in the first days – enough to cause side-effects then.The observation remains for the newer preparations.
An example is the sudden onset of sedation in depot Olanzapine in minutes and hours after a depot injection, which occurs often enough for patients to have to be under observation for this.There are other 'mechanics' to be taken into account.
At the beginning in a depot course it will take around three months for the blood levels to level off to where it is wanted to be.
Illness behaviour may persist till then, and therefore oral medication would have to continue for that time.
An example to be given special observational care is with depot Risperidone where the accumulation of medication can build up for longer, and the final level be somewhat more unpredictableWhy is it so common for patients not to take medication.
Quite often there is no routine to follow in the instruction about that importance.
A patient on their own is maybe going to have a somewhat haphazard personal and domestic life.
They more usually forget than refuse, but that leads to return of illness taking over from insight about medication [ see prospective memory study ]Two things to be said, { helpfully ] which I will make personal. From the very beginning my family member was clearly going to continue smoking
It was too far from shops for his own supply on a regular basis.I described the adverse consequences of smoking and declared a ration of ten per day, which as I would be purchasing ,
I would put out during the day so that there was always some available.Four with mid morning coffee and biscuits, four at teatime; two with the evening drink.
To make taking medication tablets easy to swallow straight-away, [ two am and pm ] I moistened fruit gums with water from the kettle
stuck the tablets to the fruit gums, and presented them with the mid-morning coffee biscuits, and the evening drink, together with the cigarettes.
The medication was stored up on the shelves above where the the coffee and evening drink were served.The tablet taking became a habit for both of us.
The routine built in it's own reminder of the importance of respecting medication.
Family carers know that a routine, minimalises the illness.
Without it 'control' of the illness by cared for and carer is lost.The other check on forgetfulness is a necessary one where there is no such routine as the one described [ in too much detail ? ]
is that the tablets remaining should be counted at appropriate intervals.
The amount remaining should be calculable from the date of the last supply .
Then, it would be clear that medication was not to be relied upon.I suppose what is equally important is the ethos around medication.
Something like this.
You had a bad time with illness – so did we, and your friends and others - experts tell us, and have told you, this medication will mitigate against illness recurring - your reputation and acceptance by anyone is at risk if your illness comes back.People around you at the time were puzzled and uneasy about it when it happened.
They will feel unable to depend on you, and be less easy in continuing with you,
if they think you are not bothering to do what is helpful in preventing the scenes happening again.
Better for all, if you do the right thing and play safe.
For you and for them.