Paranoid Schizophrenia and Nursing Interventions in a Community Mental Health setting
Schizophrenia is a severe mental illness in which individuals loose the ability to discriminate between reality and imagination, characterized by disturbances to their thoughts, behavior and feelings. About 1% of the population is predicted to suffer from schizophrenia at some point in their life (www.rethink.org), with experience of psychotic episodes such as those of schizophrenia ranging in their duration of a single crisis, to the chronic experience of schizophrenia over a life time. During episodes of schizophrenia, patients will experience a range of what is know as positive and negative symptoms associated with the condition.
Positive symptoms include delusions and hallucinations and unusual or irrational behavior (often as a result of the hallucinations and delusions). Delusions can be defined as strange thoughts or beliefs which are not founded in reality, some examples include delusions of grandeur (such as believing oneself to be the next messiah) and delusions of persecution (as in being secretly watched / followed by the police or secret service). Hallucinations are when you see (visual) hear (auditory) or smell (olfactory) things that others cannot. One of the most well known symptoms of schizophrenia is that of ‘hearing voices’. People may also experience thought disturbances such as ‘thought jumping’ (going from one line of thought to another in rapid succession) poor concentration and attention abilities (www.mind.org.uk). Negative symptoms are those which in some way take away from the individual – such as anhedonia (not getting pleasure out of activities which were previously pleasurable) and social withdrawal from social situations and a lack of interest in personal hygiene (such as not washing or changing clothes). Treatment of individuals with schizophrenia can be in hospital (forced through section or voluntarily in some cases) and in community settings, and should involve a mixture of pharmacological treatment (typical and atypical antipsychotic medications) and psychological therapies such as cognitive behavioral therapy (CBT) in order to manage current symptoms, and in preventing and minimizing future relapse and crises.
Nursing of individuals with a severe mental illness such as schizophrenia within a community setting (e.g. after discharge from hospital or when patients not under section and do not want to go to hospital) will be conducted by a community psychiatric nurse (CPN) who will often be working within a community mental health team (CMHT) from a care programme approach. The role of the CPN has diversified over recent years, and is now often nominated within the CMHT to act as the individuals’ key worker (i.e. who the patient will have most contact with in the CMHT). CPN’s can be seen to be involved in patient care interventions in a number of capacities.
The most predominant (and traditional) intervention role of the CPN may be seen in the medication management of people with schizophrenia. Typical (haloperidol) and atypical (aripiprazole, olanzapine etc) antipsychotic medication use now mean that around 70% of patients will experience some degree of relief to their psychotic symptoms (McCann, 2001). However relief is most often not absolute and the majority of patients will experience some form of side effects. In typical (older generation drugs) this is often in terms of extrapyramidal symptoms (EPS) such as movement disorders like Tardive Dyskinsia, and although newer atypical drugs are renowned for less EPS, side effects can include weight gain, sexual dysfunction and sedation. CPN’s are therefore an important contact with the patient in ensuring that they are taking their medication correctly, and in identifying patients who may be experiencing high levels of side effects who as a result are at a high risk of discontinuing their medications. By identifying such individuals, relapse can be minimized by helping the patient to engage with clinical services to investigate other medication options of which there are a good number. ‘Switching’ is a term used by professionals to define this process and it is not unusual for patients to have to switch between medications a number of times, before finding the most appropriate drug / combination. Dosage required is also a very individual factor, and therefore an important aspect of medication management is to check to signs that dosage is high enough to enable clinical relief, but also low enough to minimize side effects. CPN’s are thus often in a position to recognize if their patients are not on high enough dosages.
The way in which medication is administered will also differ between patients – some may be able to take their drugs orally, but a number of patients with schizophrenia are on a form of drug administration called depots. These are long-lasting injections of the antipsychotic, and are often used for patients who suffer severe episodes and those who have a history of non-compliance in taking their medication (Jackson-Koku, 2001). CPN’s may also act in helping people come to terms with the fact that they are suffering from an illness, as denial is common in those mental illnesses such as schizophrenia (Fung & Fry, 1999), often referred to as lacking ‘insight’ into illness, and so discuss the need for taking their medications. Providing medication related information is therefore an important part of the medication interventions that nurses are involved with, and will often include discussions about side effects, recognizing early signs of illness and other concerns the person may have.
Nurses are however becoming increasingly involved in psycho-educational (Fung & Fry, 1999) and psychological therapy (McCann, 2001) based interventions in their patient care within community settings for sufferers and their families. Such approaches have in the literature, been described as aiming at ‘increasing social functioning, decreasing distress, and reducing hospital admission rates’ (Tarrier & Birchwood, 1995) These educational interventions are so targeted on helping to reduce distress in more drug-resistant cases, to help both sufferers and their family (Leff et al, 2001) deal with the illness and learn the signs of relapse and symptom return, and as mentioned above, in increasing medication compliance through better understanding and information. (McCann, 2001) Psychological therapies such as CBT and cognitive therapy (CT) have found recognized success in treating many mental illnesses including schizophrenia including when used within community settings (Morrison et al, 2004), as are aimed at helping people deal emotionally with their illness and its associated distress, but also to help on a practical level through promoting relapse prevention strategies and reducing ‘social disability’ (Fowler, Garety & Kuipers, 1995) Coping techniques and strategies can also be discussed when CPN’s become aware and gain knowledge into what particular symptoms are causing people most distress. One example of this could be distraction techniques discussed with those who are having problems with auditory hallucinations; one method that is known for helping many people with this is to listen to music.
CPN’s often also play an important counseling role to those they support (royal college of psychiatrists,1997). Acting as key workers for people with schizophrenia gives many CPN’s the opportunity to get to know the person, and so are in a position to use the discussions they have with their patients in an intervention capacity. Counseling may help in anxiety and distress reduction, but also will provide invaluable insight for the CPN into what the person is going through, how much they understand and whether they are doing well or becoming ill. All this information will play a crucial role in the assessment capacity that the CPN also performs within the care programme.
CPN’s are thus seen to be involved in many aspects of people’s outpatient care in community settings. Especially involved in medication, information and more recently psychosocial and psychological interventions, nurses looking after people with schizophrenia within the community are central to the patients care programme, and act as an invaluable access into mental health services (McCann & Clark, 2003) for community patients.
Fowler, Garety & Kuipers, (1995) cited in McCann, E (2001) Recent developments in psychosocial interventions for people with psychosis Issues in Mental Health Nursing Vol.22,1 p99-107
Fung, C & Fry, A (1999) The role of community mental health nurses in education of clients and families about schizophrenia Australian &New Zealand Journal of Mental Health Nursing Vol. 8, 4 p162-175
Jackson-Koku, G (2001) Neuroleptics and chronic schizophrenia Mental Health Nursing Vol.21, 4 p10-14
Leff, J. Sharpley, M. Chisholm, D. Bell, R & Gamble, C (2001) Training community psychiatric nurses in schizophrenia family work: A study of clinical and economic outcomes for patients and relatives Journal of Mental Health Vol. 10, 2 p 189-197
McCann, E (2001) Recent developments in psychosocial interventions for people with psychosis Issues in Mental Health Nursing Vol.22,1 p99-107
McCann, T & Clark, E. (2003) A grounded theory study of the role that nursesplay in increasing clients’ willingness to access community mental health services International Journal of Mental Health Nursing Vol.12, 4 p279-288
Morrison, A. Renton, J. Williams, S. Dunn, H. Knight, A. Kreutz, M. Nothard,S. Patel, U & Dunn, G (2004) Delivering cognitive therapy to people with psychosis in a community mental health setting: an effectiveness study Acta Psychiatrica Scandinavica Vol,110, 1 p36-44
Tarrier & Birchwood (1995) cited in McCann, E (2001) Recent developments in psychosocial interventions for people with psychosis Issues in Mental Health Nursing Vol.22,1 p99-107
Community Psychiatric Nursing Occasional PaperOP40 (1997) Royal College of Psychiatrists, London