A group of men and women gather in a conference room of an office building north of Chicago the second Monday of every month.
Usually 10-15 group members gather to talk, to get advice, to share, to laugh, and most importantly, to accept and support each other.
Occasionally, the group may host a guest speaker to learn about a health topic or they may play games to have some competitive fun.
The group members are diverse in many different ways.
John likes to bowl. Michael enjoys meditating. Robert has a master’s degree and loves to spend time with his nephews. Jean wants to write a book. Rich has worked at a drug store for almost 21 years and wants to travel. Tom is the youngest at 25, and Joe is the oldest at 59.
What they have in common is that they are members of a group of people with schizophrenia who take an antipsychotic medicine and receive local mental health services. They meet monthly as part of their treatment plan as a peer support group.
Mental Illness
An estimated 19.8% of Americans ages 18 and older-or about one in five adults-suffer from a diagnosable mental disorder.
The 2011 National Survey on Drug Use and Health (NSDUH) shows that 11.5 million adults (5% of the adult population) had serious mental illness.1
Serious mental illness is defined as mental illness that resulted in serious functional impairment, which substantially interfered with or limited one or more major life activities. By 2020, behavioral health disorders will surpass all physical diseases as a major cause of disability worldwide.2
The consequences of untreated mental illness for the individual and society are tremendous: unnecessary disability, unemployment, substance abuse, homelessness, inappropriate incarceration and suicide.
The economic cost of untreated mental illness is more than $100 billion each year in the U.S.
Even though mental disorders are widespread in the population, the main burden of illness is concentrated in the small proportion of the population who suffer from a serious mental illness, such as schizophrenia.2
While the burden of mental illness on society is high, the effects of stigma limit understanding and funding that support this population. Stigma erodes confidence that mental disorders are treatable health conditions and erects attitudinal, structural and financial barriers to effective treatment and recovery.3
Nurses have a critical role in de-stigmatizing mental illness, properly assessing, referring and advocating for our clients with mental illness.
Fundamentals of Treatment for Schizophrenia
Schizophrenia is a genetically determined brain disorder characterized by:
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positive symptoms (primarily delusions and hallucinations);
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negative symptoms (withdrawal, flat affect, anhedonia, and anergia);
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cognitive impairment (lower IQ, deficits in attention, executive function, working memory
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long-term memory, speeded motor pursuit, and verbal fluency); and
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mood disturbances,and suicidality.4
The concept of recovery emphasizes the need to provide access to treatments and services that are effective in both decreasing manifestations of the disorder and in assisting individuals to lead maximally productive and personally meaningful lives.5
Treatment of people with schizophrenia includes a collaboration of pharmacological and psychosocial treatments and supports.
Medication
Antipsychotic medications are used to treat schizophrenia and schizophrenia-related disorders. Some of these medications have been available since the mid 1950’s. They are also called conventional “typical” antipsychotics.
Some of the more commonly used medications include: chlorpromazine (Thorazine) haloperidol (Haldol), perphenazine (generic only) and fluphenazine (generic only.)
In the 1990’s, new antipsychotic medications were developed called second generation, or “atypical” antipsychotics. These include: risperadone (Risperadal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), paliperidone (Invega), lurasidone (Latuda) and clozapine (Clozaril).
The use of antipsychotic medications is a difficult trade-off between the benefit of alleviating psychotic symptoms and the risk of adverse effects. The newer second-generation antipsychotics generally tend to cause more problems related to metabolic syndrome, such as obesity and type 2 diabetes mellitus.
The older first-generation antipsychotics are more likely to be associated with the movement disorders of extrapyramidal symptoms (EPS) and life threatening neuroleptic malignant syndrome (NMS).
Anticholinergic effects can be prominent in first-generation antipsychotics and second-generation clozapine. All antipsychotic medications are associated with an increased likelihood of sedation, sexual dysfunction, postural hypotension, cardiac arrhythmia, and sudden cardiac death.6
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Psychosocial Treatment
A psychosocial treatment plan combines multiple components to provide adequate guidance and support to address functional, social, medical, financial, environmental and educational needs of the client.
Members of the psychosocial treatment team may include social workers, therapists, nurses, case managers and resources who are able to devise and supervise an individualized plan for the client.
The Schizophrenia Patient Outcomes Research Team (PORT) publishes a comprehensive list of evidence-based psychosocial treatment interventions for persons with schizophrenia and report recommendations based on a review of literature in each recognized intervention area.
The most recent review process produced eight psychosocial treatment recommendations for patients with schizophrenia in the following areas:
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assertive community treatment (ACT);
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supported employment;
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cognitive behavioral therapy (CBT);
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family-based services;
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token economy;
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skills training;
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psychosocial interventions for alcohol and substance use disorders; and
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psychosocial interventions for weight management.7
A Danish schizophrenia research project compared psychodynamic psychotherapy with standard treatment in patients with psychosis with a first-episode schizophrenia spectrum disorder. The study was designed as a prospective, comparative, longitudinal, multisite investigation over a two-year period. A total of 269 patients were treated with either individual supportive psychodynamic psychotherapy (SPP) in addition to medication treatment, or with medication alone (treatment as usual TaU).
The intervention group improved significantly on measures of symptoms and functional outcomes measured by Positive and Negative Syndrome Scale (PANSS) and Global Assessment of Functioning (GAF) scores. This study significantly favored SPP in combination with TaU over TaU alone in the treatment for patients with schizophrenic first-episode psychoses
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Support Services Team
Back in Chicago, members of the support group for patients with schizophrenia described in the opening paragraph have been successful by using the services of their local community health center.
The majority meet with a psychiatrist monthly, a therapist monthly and has a case manager. Nearly all of the members are clients of the Assertive Community Treatment (ACT) program which provides subsidized housing and assistance with daily living skills.
The case manager’s complex role includes monitoring the client’s status, helping the client maintain engagement in treatment and access services. The case manager may also act as the patient’s major advocate in dealing with landlords, social service agencies and utility companies.
The health system also has a crisis care program (CCP) that provides 24-hour crisis counseling by phone and in person. The client and the support service specialists operate as a collaborative team focused on recovery.
A written survey was administered to the support group clients January 2013 to gain an understanding of their perspective. See Table 1 for responses the survey.
Recover & Restore
Untreated mental illness places a large burden on society.
Recovery is often challenging and requires multiple levels of care as well as persistence and determination on the part of the health care providers and the patient. Successful treatment involves individualized treatment plans that include collaborative care as well as motivation by the patient.
The disease is treatable and persons can recover to productive contributing lives. Our role as nurses put us in an important position to help properly assess and refer and advocate for our mentally ill patients.
References for this article can be accessed here.
Mary Bonaccorsi is a family nurse practitioner at Swedish Covenant Hospital in Chicago. Leslie Fields is a psychiatric nurse at Lake County Health Department in Waukegan Ill.
