Causes There is an inherited element: parents, children or siblings of schizophrenic sufferers have a one in ten chance of developing the disorder; a twin has a 50 per cent chance if the other twin has schizophrenia. Some BRAIN disorders such as temporal lobe EPILEPSY, tumours and ENCEPHALITIS seem to be linked with schizophrenia. Certain drugs – for example, AMPHETAMINES – can precipitate schizophrenia and DOPAMINE-blocking drugs often relieve schizophrenic symptoms. Stress may worsen schizophrenia and recreational drugs may trigger an attack.
Symptoms These usually develop gradually until the individual’s behaviour becomes so distrubing or debilitating that work, relationships and basic activities such as eating and sleeping are interrupted. The patient may have disturbed perception with auditory HALLUCINATIONS, illogical thought-processes and DELUSIONS; low-key emotions (‘?at affect’); a sense of being invaded or controlled by outside forces; a lack of INSIGHT and inability to acknowledge reality; lethargy and/or agitation; a disrespect for personal appearance and hygiene; and a tendency to act strangely. Violence is rare although some sufferers commit violent acts which they believe their ‘inner voices’ have commanded.
Relatives and friends may try to cope with the affected person at home, but as severe episodes may last several months and require regular administration of powerful drugs – patients are not always good at taking their medication
– hospital admission may be necessary.
Treatment So far there is no cure for schizophrenia. Since the 1950s, however, a group of drugs called antipsychotics – also described as NEUROLEPTICS or major tranquillisers – have relieved ?orid symptoms such as thought disorder, hallucinations and delusions as well as preventing relapses, thus allowing many people to leave psychiatric hospitals and live more independently outside. Only some of these drugs have a tranquillising e?ect, but their sedative properties can calm patients with an acute attack. CHLORPROMAZINE is one such drug and is commonly used when treatment starts or to deal with an emergency. Halperidol, tri?uoperazine and pimozide are other drugs in the group; these have less sedative effects so are useful in treating those whose prominent symptoms are apathy and lethargy.
The antipsychotics’ mode of action is by blocking the activity of DOPAMINE, the chemical messenger in the brain that is faulty in schizophrenia. The drugs quicken the onset and prolong the remission of the disorder, and it is very important that patients take them inde?nitely. This is easier to ensure when a patient is in hospital or in a stable domestic environment.
CLOZAPINE – a newer, atypical antipsychotic drug – is used for treating schizophrenic patients unresponsive to, or intolerant of, conventional antipsychotics. It may cause AGRANULOCYTOSIS and use is con?ned to patients registered with the Clorazil (the drug’s registered name) Patient Monitoring Service. Amisulpride, olanzapine, quetiapine, risperidone, sertindole and zotepine are other antipsychotic drugs described as ‘atypical’ by the British National Formulary; they may be better tolerated than other antipsychotics, and their varying properties mean that they can be targeted at patients with a particular grouping of symptoms. They should, however, be used with caution.
The welcome long-term shift of mentally ill patients from large hospitals to community care (often in small units) has, because of a lack of resources, led to some schizophrenic patients not being properly supervised with the result that they fail to take their medication regularly. This leads to a recurrence of symptoms and there have been occasional episodes of such patients in community care becoming a danger to themselves and to the public.
The antipsychotic drugs are powerful agents and have a range of potentially troubling side-effects. These include blurred vision, constipation, dizziness, dry mouth, limb restlessness, shaking, sti?ness, weight gain, and in the long term, TARDIVE DYSKINESIA (abnormal movements and walking) which affects about 20 per cent of those under treatment. Some drugs can be given by long-term depot injection: these include compounds of ?upenthixol, zuclopenthixol and haloperidol.
Prognosis About 25 per cent of sufferers recover fully from their ?rst attack. Another 25 per cent are disabled by chronic schizophrenia, never recover and are unable to live independently. The remainder are between these extremes. There is a high risk of suicide.... schizophrenia
Delirium (confusion) In some old people, acute confusion is a common e?ect of physical illness. Elderly people are often referred to as being ‘confused’; unfortunately this term is often inappropriately applied to a wide range of eccentricities of speech and behaviour as if it were a diagnosis. It can be applied to a patient with the early memory loss of DEMENTIA – forgetful, disorientated and wandering; to the dejected old person with depression, often termed pseudo-dementia; to the patient whose consciousness is clouded in the delirium of acute illness; to the paranoid deluded sufferer of late-onset SCHIZOPHRENIA; or even to the patient presenting with the acute DYSPHASIA and incoherence of a stroke. Drug therapy may be a cause, especially in the elderly.
Delirium tremens is the form of delirium most commonly due to withdrawal from alcohol, if a person is dependent on it (see DEPENDENCE). There is restlessness, fear or even terror accompanied by vivid, usually visual, hallucinations or illusions. The level of consciousness is impaired and the patient may be disorientated as regards time, place and person.
Treatment is, as a rule, the treatment of causes. (See also ALCOHOL.) As the delirium in fevers is due partly to high temperature, this should be lowered by tepid sponging. Careful nursing is one of the keystones of successful treatment, which includes ensuring that ample ?uids are taken and nutrition is maintained.... delirium
Treatment Hypochondriacal patients may also develop physical illness, and any new symptoms must always be carefully evaluated. In most patients the condition is secondary, and treatment should be directed to the underlying depression or schizophrenia. In the rare cases of primary hypochondriasis, supportive measures are the mainstay of treatment.... hypochondriasis
Doctors make the diagnosis of depression when they believe a patient to be ill with the latter condition, which may affect physical health and in some instances be life-threatening. This form of depression is common, with up to 15 per cent of the population suffering from it at any one time, while about 20 per cent of adults have ‘medical’ depression at some time during their lives – such that it is one of the most commonly presenting disorders in general practice. Women seem more liable to develop depression than men, with one in six of the former and one in nine of the latter seeking medical help.
Manic depression is a serious form of the disorder that recurs throughout life and is manifested by bouts of abnormal elation – the manic stage. Both the manic and depressive phases are commonly accompanied by psychotic symptoms such as delusions, hallucinations and a loss of sense of reality. This combination is sometimes termed a manic-depressive psychosis or bipolar affective disorder because of the illness’s division into two parts. Another psychiatric description is the catch-all term ‘affective disorder’.
Symptoms These vary with the illness’s severity. Anxiety and variable moods are the main symptoms in mild depression. The sufferer may cry without any reason or be unresponsive to relatives and friends. In its more severe form, depression presents with a loss of appetite, sleeping problems, lack of interest in and enjoyment of social activities, tiredness for no obvious reason, an indi?erence to sexual activity and a lack of concentration. The individual’s physical and mental activities slow down and he or she may contemplate suicide. Symptoms may vary during the 24 hours, being less troublesome during the latter part of the day and worse at night. Some people get depressed during the winter months, probably a consequence of the long hours of darkness: this disorder – SEASONAL AFFECTIVE DISORDER SYNDROME, or SADS – is thought to be more common in populations living in areas with long winters and limited daylight. Untreated, a person with depressive symptoms may steadily worsen, even withdrawing to bed for much of the time, and allowing his or her personal appearance, hygiene and environment to deteriorate. Children and adolescents may also suffer from depression and the disorder is not always recognised.
Causes A real depressive illness rarely has a single obvious cause, although sometimes the death of a close relative, loss of employment or a broken personal relationship may trigger a bout. Depression probably has a genetic background; for instance, manic depression seems to run in some families. Viral infections sometimes cause depression, and hormonal disorders – for example, HYPOTHYROIDISM or postnatal hormonal disturbances (postnatal depression) – will cause it. Di?cult family or social relations can contribute to the development of the disorder. Depression is believed to occur because of chemical changes in the transmission of signals in the nervous system, with a reduction in the neurochemicals that facilitate the passage of messages throughout the system.
Treatment This depends on the type and severity of the depression. These are three main forms. PSYCHOTHERAPY either on a one-to-one basis or as part of a group: this is valuable for those whose depression is the result of lifestyle or personality problems. Various types of psychotherapy are available. DRUG TREATMENT is the most common method and is particularly helpful for those with physical symptoms. ANTIDEPRESSANT DRUGS are divided into three main groups: TRICYCLIC ANTIDEPRESSANT DRUGS (amitriptyline, imipramine and dothiepin are examples); MONOAMINE OXIDASE INHIBITORS (MAOIS) (phenelzine, isocarboxazid and tranylcypromine are examples); and SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) (?uoxetine – well known as Prozac®, ?uvoxamine and paroxetine are examples). For manic depression, lithium carbonate is the main preventive drug and it is also used for persistent depression that fails to respond to other treatments. Long-term lithium treatment reduces the likelihood of relapse in about 80 per cent of manic depressives, but the margin between control and toxic side-effects is narrow, so the drug must be carefully supervised. Indeed, all drug treatment for depression needs regular monitoring as the substances have powerful chemical properties with consequential side-effects in some people. Furthermore, the nature of the illness means that some sufferers forget or do not want to take the medication. ELECTROCONVULSIVE THERAPY (ECT) If drug treatments fail, severely depressed patients may be considered for ECT. This treatment has been used for many years but is now only rarely recommended. Given under general anaesthetic, in appropriate circumstances, ECT is safe and e?ective and may even be life-saving, though temporary impairment of memory may occur. Because the treatment was often misused in the past, it still carries a reputation that worries patients and relatives; hence careful assessment and counselling are essential before use is recommended.
Some patients with depression – particularly those with manic depression or who are a danger to themselves or to the public, or who are suicidal – may need admission to hospital, or in severe cases to a secure unit, in order to initiate treatment. But as far as possible patients are treated in the community (see MENTAL ILLNESS).... depression
are separated, one of them almost always quickly loses the symptoms, which have been imposed by the dominant, and genuinely psychotic, partner.... folie à deux
Symptoms may include extravagant spending, repeatedly starting new tasks; sleeping less; increased appetite for food, alcohol, sex, and exercise; outbursts of inappropriate anger, laughter, or sudden socializing; and delusions of grandeur. If symptoms are mild, the condition is called hypomania.
Severe mania usually needs treatment in hospital with antipsychotic drugs. Relapses may be prevented by taking lithium or carbamazepine.... mania
Early onset Alzheimer’s disease, in which symptoms develop before age 60, is inherited as a dominant disorder. Late onset Alzheimer’s disease is associated with a number of genes, including 3 that
are responsible for the production of the blood protein apolipoprotein E. These genes also result in the deposition of a protein called beta amyloid in the brain. Other chemical abnormalities may include deficiency of the neurotransmitter acetylcholine.
The features of Alzheimer’s disease vary, but there are 3 broad stages. At first, the person becomes increasingly forgetful, and problems with memory may cause anxiety and depression. In the 2nd stage, loss of memory, particularly for recent events, gradually becomes more severe, and there may be disorientation as to time or place. The person’s concentration and numerical ability decline, and there is noticeable dysphasia (inability to find the right word). Anxiety increases, mood changes are unpredictable, and personality changes may occur. Finally, confusion becomes profound. There may be symptoms of psychosis, such as hallucinations and delusions. Signs of nervous system disease, such as abnormal reflexes and faecal or urinary incontinence, begin to develop.
Alzheimer’s disease is usually diagnosed from the symptoms, but tests including blood tests and CT scanning or MRI of the brain may be needed to exclude treatable causes of dementia.
The most important aspect of treatment for Alzheimer’s disease is the provision of suitable nursing and social care for sufferers and support for their relatives. Tranquillizer drugs can often improve difficult behaviour and help with sleep. Treatment with drugs such as donepezil and rivastigmine may slow the progress of the disease for a time, but side effects such as nausea and dizziness may occur.... alzheimer’s disease
In high doses, amfetamines can cause tremor, sweating, anxiety, and sleeping problems. Delusions, hallucinations, high blood pressure, and seizures may also occur. Prolonged use may produce tolerance and drug dependence.
Amfetamines are often abused for their stimulant effect.... amfetamine drugs
Psychiatrists like to categorise mental illnesses because mental signs and symptoms do occur together in clusters or syndromes, each tending to respond to certain treatments. The idea that illnesses can be diagnosed simply by recognising their symptom patterns may not seem very scienti?c in these days of high technology. For most common mental illnesses, however, this is the only method of diagnosis; whatever is going wrong in the brain is usually too poorly understood and too subtle to show up in laboratory tests or computed tomography scans of the brain. And symptom-based definitions of mental illnesses are, generally, a lot more meaningful than the vague lay term ‘nervous breakdown’, which is used to cover an attack of anything from AGORAPHOBIA to total inability to function.
There is still a lot to learn about the workings of the brain, but psychiatry has developed plenty of practical knowledge about the probable causes of mental illness, ways of relieving symptoms, and ways of aiding recovery. Most experts now believe that mental illnesses generally arise from di?erent combinations of inherited risk and psychological STRESS, sometimes with additional environmental exposure – for example, viruses, drugs or ALCOHOL.
The range of common mental illnesses includes anxiety states, PHOBIA, DEPRESSION, alcohol and drug problems, the EATING DISORDERS anorexia and bulimia nervosa, MANIC DEPRESSION, SCHIZOPHRENIA, DEMENTIA, and a group of problems related to coping with life that psychiatrists call personality disorders.
Of these mental illnesses, dementia is the best understood. It is an irreversible and fatal form of mental deterioration (starting with forgetfulness and eventually leading to severe failure of all the brain’s functions), caused by rapid death of brain cells and consequent brain shrinkage. Schizophrenia is another serious mental illness which disrupts thought-processes, speech, emotions and perception (how the brain handles signals from the ?ve senses). Manic depression, in which prolonged ‘highs’ of extremely elevated mood and overexcitement alternate with abject misery, has similar effects on the mental processes. In both schizophrenia and manic depression the sufferer loses touch with reality, develops unshakeable but completely unrealistic ideas (delusions), and hallucinates (vividly experiences sensations that are not real, e.g. hears voices when there is nobody there). This triad of symptoms is called psychosis and it is what lay people, through fear and lack of understanding, sometimes call lunacy, madness or insanity.
The other mental illnesses mentioned above are sometimes called neuroses. But the term has become derogatory in ordinary lay language; indeed, many people assume that neuroses are mild disorders that only affect weak people who cannot ‘pull themselves together’, while psychoses are always severe. In reality, psychoses can be brief and reversible and neuroses can cause lifelong disability.
However de?ned and categorised, mental illness is a big public-health problem. In the UK, up to one in ?ve women and around one in seven men have had mental illness. About half a million people in Britain suffer from schizophrenia: it is three times commoner than cancer. And at any one time, up to a tenth of the adult population is ill with depression.
Treatment settings Most people with mental-health problems get the help they need from their own family doctor(s), without ever seeing a psychiatrist. General practictitioners in Britain treat nine out of ten recognised mental-health problems and see around 12 million adults with mental illness each year. Even for the one in ten of these patients referred to psychiatrists, general practitioners usually handle those problems that continue or recur.
Psychiatrists, psychiatric nurses, social workers, psychologists, counsellors and therapists often see patients at local doctors’ surgeries and will do home visits if necessary. Community mental-health centres – like general-practice health centres but catering solely for mental-health problems – o?er another short-cut to psychiatric help. The more traditional, and still more common, route to a psychiatrist for many people, however, is from the general practititioner to a hospital outpatient department.
Specialist psychiatric help In many ways, a visit to a psychiatrist is much like any trip to a hospital doctor – and, indeed, psychiatric clinics are often based in the outpatient departments of general hospitals. First appointments with psychiatrists can last an hour or more because the psychiatrist – and sometimes other members of the team such as nurses, doctors in training, and social workers – need to ask lots of questions and record the whole consultation in a set of con?dential case notes.
Psychiatric assessment usually includes an interview and an examination, and is sometimes backed up by a range of tests. The interview begins with the patient’s history – the personal story that explains how and, to some extent, why help is needed now. Mental-health problems almost invariably develop from a mixture of causes – emotional, social, physical and familial – and it helps psychiatrists to know what the people they see are normally like and what kind of lives they have led. These questions may seem unnecessarily intrusive, but they allow psychiatrists to understand patients’ problems and decide on the best way to help them.
The next stage in assessment is the mental-state examination. This is how psychiatrists examine minds, or at least their current state. Mental-state examination entails asking more questions and using careful observation to assess feelings, thoughts and mental symptoms, as well as the way the mind is working (for example, in terms of memory and concentration). During ?rst consultations psychiatrists usually make diagnoses and explain them. The boundary between a life problem that will clear up spontaneously and a mental illness that needs treatment is sometimes quite blurred; one consultation may be enough to put the problem in perspective and help to solve it.
Further assessment in the clinic may be needed, or some additional tests. Simple blood tests can be done in outpatient clinics but other investigations will mean referral to another department, usually on another day.
Further assessment and tests
PSYCHOLOGICAL TESTS Psychologists work in or alongside the psychiatric team, helping in both assessment and treatment. The range of psychological tests studies memory, intelligence, personality, perception and capability for abstract thinking. PHYSICAL TESTS Blood tests and brain scans may be useful to rule out a physical illness causing psychological symptoms. SOCIAL ASSESSMENT Many patients have social diffculties that can be teased out and helped by a psychiatric social worker. ‘Approved social workers’ have special training in the use of the Mental Health Act, the law that authorises compulsory admissions to psychiatric hospitals and compulsory psychiatric treatments. These social workers also know about all the mental-health services o?ered by local councils and voluntary organisations, and can refer clients to them. The role of some social workers has been widened greatly in recent years by the expansion of community care. OCCUPATIONAL THERAPY ASSESSMENT Mental-health problems causing practical disabilities – for instance, inability to work, cook or look after oneself – can be assessed and helped by occupational therapists.
Treatment The aims of psychiatric treatment are to help sufferers shake o?, or at least cope with, symptoms and to gain or regain an acceptable quality of life. A range of psychological and physical treatments is available.
COUNSELLING This is a widely used ‘talking cure’, particularly in general practice. Counsellors listen to their clients, help them to explore feelings, and help them to ?nd personal and practical solutions to their problems. Counsellors do not probe into clients’ pasts or analyse them. PSYCHOTHERAPY This is the best known ‘talking cure’. The term psychotherapy is a generalisation covering many di?erent concepts. They all started, however, with Sigmund Freud (see FREUDIAN THEORY), the father of modern psychotherapy. Freud was a doctor who discovered that, as well as the conscious thoughts that guide our feelings and actions, there are powerful psychological forces of which we are not usually aware. Applying his theories to his patients’ freely expressed thoughts, Freud was able to cure many illnesses, some of which had been presumed completely physical. This was the beginning of individual analytical psychotherapy, or PSYCHOANALYSIS. Although Freud’s principles underpin all subsequent theories about the psyche, many di?erent schools of thought have emerged and in?uenced psychotherapists (see ADLER; JUNGIAN ANALYSIS; PSYCHOTHERAPY). BEHAVIOUR THERAPY This springs from theories of human behaviour, many of which are based on studies of animals. The therapists, mostly psychologists, help people to look at problematic patterns of behaviour and thought, and to change them. Cognitive therapy is very e?ective, particularly in depression and eating disorders. PHYSICAL TREATMENTS The most widely used physical treatments in psychiatry are drugs. Tranquillising and anxiety-reducing BENZODIAZEPINES like diazepam, well known by its trade name of Valium, were prescribed widely in the 1960s and 70s because they seemed an e?ective and safe substitute for barbiturates. Benzodiazepines are, however, addictive and are now recommended only for short-term relief of anxiety that is severe, disabling, or unacceptably distressing. They are also used for short-term treatment of patients drying out from alcohol.
ANTIDEPRESSANT DRUGS like amitriptyline and ?uoxetine are given to lift depressed mood and to relieve the physical symptoms that sometimes occur in depression, such as insomnia and poor appetite. The side-effects of antidepressants are mostly relatively mild, when recommended doses are not exceeded – although one group, the monoamine oxidase inhibitors, can lead to sudden and dangerous high blood pressure if taken with certain foods.
Manic depression virtually always has to be treated with mood-stabilising drugs. Lithium carbonate is used in acute mania to lower mood and stop psychotic symptoms; it can also be used in severe depression. However lithium’s main use is to prevent relapse in manic depression. Long-term unwanted effects may include kidney and thyroid problems, and short-term problems in the nervous system and kidney may occur if the blood concentration of lithium is too high – therefore it must be monitored by regular blood tests. Carbamazepine, a treatment for EPILEPSY, has also been found to stabilise mood, and also necessitates blood tests.
Antipsychotic drugs, also called neuroleptics, and major tranquillisers are the only e?ective treatments for relieving serious mental illnesses with hallucinations and delusions. They are used mainly in schizophrenia and include the short-acting drugs chlorpromazine and clozapine as well as the long-lasting injections given once every few weeks like ?uphenazine decanoate. In the long term, however, some of the older antipsychotic drugs can cause a brain problem called TARDIVE DYSKINESIA that affects control of movement and is not always reversible. And the antipsychotic drugs’ short-term side-effects such as shaking and sti?ness sometimes have to be counteracted by other drugs called anticholinergic drugs such as procyclidine and benzhexol. Newer antipsychotic drugs such as clozapine do not cause tardive dyskinesia, but clozapine cannot be given as a long-lasting injection and its concentration in the body has to be monitored by regular blood tests to avoid toxicity. OTHER PHYSICAL TREATMENTS The other two physical treatments used in psychiatry are particularly controversial: electroconvulsive therapy (ECT) and psychosurgery. In ECT, which can be life-saving for patients who have severe life-threatening depression, a small electric current is passed through the brain to induce a ?t or seizure. Before the treatment the patient is anaesthetised and given a muscle-relaxing injection that reduces the magnitude of the ?t to a slight twitching or shaking. Scientists do not really understand how ECT works, but it does, for carefully selected patients. Psychosurgery – operating on the brain to alleviate psychiatric illness or di?cult personality traits – is extremely uncommon these days. Stereo-tactic surgery, in which small cuts are made in speci?c brain ?bres under X-ray guidance, has super-seded the more generalised lobotomies of old. The Mental Health Act 1983 ensures that psychosurgery is performed only when the patient has given fully informed consent and a second medical opinion has agreed that it is necessary. For all other psychiatric treatments (except another rare treatment, hormone implantation for reducing the sex drive of sex o?enders), either consent or a second opinion is needed – not both. TREATMENT IN HOSPITAL Psychiatric wards do not look like medical or surgical wards and sta? may not wear uniforms. Patients do not need to be in their beds during the day, so the beds are in separate dormitories. The main part of most wards is a living space with a day room, an activity and television room, quiet rooms, a dining room, and a kitchen. Ward life usually has a certain routine. The day often starts with a community meeting at which patients and nurses discuss issues that affect the whole ward. Patients may go to the occupational therapy department during the day, but there may also be some therapy groups on the ward, such as relaxation training. Patients’ symptoms and problems are assessed continuously during a stay in hospital. When patients seem well enough they are allowed home for trial periods; then discharge can be arranged. Patients are usually followed up in the outpatient clinic at least once.
TREATING PATIENTS WITH ACUTE PSYCHIATRIC ILLNESS Psychiatric emergencies – patients with acute psychiatric illness – may develop from psychological, physical, or practical crises. Any of these crises may need quick professional intervention. Relatives and friends often have to get this urgent help because the sufferer is not ?t enough to do it or, if psychotic, does not recognise the need. First, they should ring the person’s general practitioner. If the general practitioner is not available and help is needed very urgently, relatives or friends should phone the local social-services department and ask for the duty social worker (on 24-hour call). In a dire emergency, the police will know what to do.
Any disturbed adult who threatens his or her own or others’ health and safety and refuses psychiatric help may be moved and detained by law. The Mental Health Act of 1983 authorises emergency assessment and treatment of any person with apparent psychiatric problems that ful?l these criteria.
Although admission to hospital may be the best solution, there are other ways that psychiatric services can respond to emergencies. In some districts there are ‘crisis intervention’ teams of psychiatrists, nurses, and social workers who can visit patients urgently at home (at a GP’s request) and, sometimes, avert unnecessary admission. And research has shown that home treatment for a range of acute psychiatric problems can be e?ective.
LONG-TERM TREATMENT AND COMMUNITY CARE Long-term treatment is often provided by GPs with support and guidance from psychiatric teams. That is ?ne for people whose problems allow them to look after themselves, and for those with plenty of support from family and friends. But some people need much more intensive long-term treatment and many need help with running their daily lives.
Since the 1950s, successive governments have closed the old psychiatric hospitals and have tried to provide as much care as possible outside hospital – in ‘the community’. Community care is e?ective as long as everyone who needs inpatient care, or residential care, can have it. But demand exceeds supply. Research has shown that some homeless people have long-term mental illnesses and have somehow lost touch with psychiatric services. Many more have developed more general long-term health problems, particularly related to alcohol, without ever getting help.
The NHS and Community Care Act 1990, in force since 1993, established a new breed of professionals called care managers to assess people whose long-term illnesses and disabilities make them unable to cope completely independently with life. Care managers are given budgets by local councils to assess people’s needs and to arrange for them tailor-made packages of care, including services like home helps and day centres. But co-ordination between health and social services has sometimes failed – and resources are limited – and the government decided in 1997 to tighten up arrangements and pool community-care budgets.
Since 1992 psychiatrists have had to ensure that people with severe mental illnesses have full programmes of care set up before discharge from hospital, to be overseen by named key workers. And since 1996 psychiatrists have used a new power called Supervised Discharge to ensure that the most vulnerable patients cannot lose touch with mental-health services. There is not, however, any law that allows compulsory treatment in the community.
There is ample evidence that community care can work and that it need not cost more than hospital care. Critics argue, however, that even one tragedy resulting from inadequate care, perhaps a suicide or even a homicide, should reverse the march to community care. And, according to the National Schizophrenia Fellowship, many of the 10–15 homicides a year carried out by people with severe mental illnesses result from inadequate community care.
Further information can be obtained from the Mental Health Act Commission, and from MIND, the National Association for Mental Health. MIND also acts as a campaigning and advice organisation on all aspects of mental health.... mental illness
The main symptoms of dementia are progressive memory loss, disorientation, and confusion. Sudden outbursts or embarrassing behaviour may be the first signs of the condition. Unpleasant personality traits may be magnified; families may have to endure accusations, unreasonable demands, or even assault. Paranoia, depression, and delusions may occur as the disease worsens. Irritability or anxiety gives way to indifference towards all feelings. Personal habits deteriorate, and speech becomes incoherent. Affected people may eventually need total nursing care.
Management of the most common
Alzheimer-type illness is based on the treatment of symptoms. Sedative drugs may be given for restlessness or paranoia. Drugs for dementia, for example donepezil, can slow mental decline in some people with mild to moderate Alzheimer’s disease (see acetylcholinesterase inhibitors).... dementia
Abnormalities in brain biochemistry, or in the structure and/or function of certain nerve pathways within the brain, could underlie manic–depressive illness. An inherited tendency is also an established causative factor.Severe manic–depressive illness often needs hospital treatment. Antidepressant drugs and/or ECT are used to treat depression, and antipsychotic drugs are given to control manic symptoms. Carbamazepine or lithium may be used to prevent relapse.
Group therapy, family therapy, and individual psychotherapy may be useful in treatment. Cognitive–behavioural therapy may also be helpful. With treatment, more than 80 per cent of patients improve or remain stable. Even those with severe illness may be restored to near normal health with lithium.... manic–depressive illness
Most mothers first get the “blues” 4–5 days after childbirth and may feel miserable, irritable, and tearful. The cause is hormonal changes, perhaps coupled with a sense of anticlimax or an overwhelming sense of responsibility for the baby. With reassurance and support, the depression usually passes in 2–3 days. In about 10–15 per cent of women, the depression lasts for weeks and causes a constant feeling of tiredness, difficulty in sleeping, loss of appetite, and restlessness. The condition usually clears up of its own accord or is treated with antidepressant drugs.
Depressive psychosis usually starts 2–3 weeks after childbirth, causing severe mental confusion, feelings of worthlessness, threats of suicide or harm to the baby, and sometimes delusions.
Hospital admission, ideally with the baby, and antidepressant drugs are often needed.... postnatal depression
Incoherent thoughts occur in all types of confusion, including dementia and delirium. Rapidly jumping from one idea
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