Approaches to Mental Health

The primary problem Mandy is currently facing is that of hearing voices, which is disturbing and limiting her ability to lead a normal life. Mandy’s condition is aggravated by stress and dissatisfaction in her present life, alongside her childhood experiences. However, this is possibly an assumption, which will require some formal assessments to ascertain. This paper aims to understand Mandy’s disturbing or unusual experiences from a treatment perspective, whether they emanate from a psychological, medical, or social needs standpoint. The essay explores various mainstream treatment and support options available to meet Mandy’s needs. The three alternative approaches for supporting individuals who hear, such as Mandy’s case, include clinical psychological approach, psychiatric diagnosis, and social/service level interventions. The three methods are the mainstream treatment and support options explored or adopted in this paper for Mandy’s case.

Assessing Mandy’s Situation

From a psychiatric perspective, Mandy’s situation can be categorized under mood disorders. The patient sounds unhappy, and with the voices, she is hearing, it practical to assume that Mandy is experiencing a psychotic disorder. Several psychotic diseases fall under the category of Mandy’s condition, including depression. Severe depression can cause one to hear voices. However, Mandy’s symptoms are mainly associated with psychosis and schizophrenia, severe mental illnesses that cause individuals to interpret reality unusually (Venables, 2017). The schizophrenia condition may generate a combination of delusions, hallucinations, and exceedingly disordered behavior and thinking that can be disabling or impair daily functioning; thus requires long-life treatment (Northoff & Duncan, 2016). Psychosis and schizophrenia diagnosis denotes a major psychiatric disorder where an individual’s perceptions, behavior, moods, and thoughts are significantly changed. Patients with schizophrenia have varying unique combinations of experiences and symptoms, depending on particular circumstances (Venables, 2017).

The study also shows that individuals with psychosis and schizophrenia are prone to affective dysfunction and comorbidities, with symptom structure, including aspects of depressions and associated symptoms (NICE 2014). Almost a third of the people with psychosis and schizophrenia experience social anxiety disorder, also known as social phobia, often characterized by social settings’ fear. People with anxiety disorder, often attributed to psychosis and schizophrenia, also have challenges talking to or interacting with new people or feeling free in a gathering for fear of judgment or being scrutinized by other people (NICE 2014). The evidence-based descriptions or symptoms described in this section are typical of Mandy’s situation, which prompt a conclusion that she may have psychosis and schizophrenia. For instance, Mandy found herself unable to hold her emotions after being accused by one of the workplace clients. She ended up shouting to the customer. The next day, Mandy gets up with a common cold, which she presented to her boss to justify taking a leave from work. Interestingly, Mandy stayed off work for about two weeks. She only leaves the house for a run. Mandy has also refused to tell anybody about hearing voices, which perhaps might mean the fear of being judged.

Mainstream Psychiatric Treatment and Support Options For Mandy

Study shows that the treatment and management schizophrenia and psychosis between the 1850s and 1950s were conducted in a massive asylum where the majority of the patients remained confined for most of their lives. However, with the development of the “post-war welfare state,” housing and benefits were made readily available to society, alongside the introduction of antipsychotic drugs and the rise of human rights groups for people with mental health complications. Such development prompted gradual shifts in government policies, leading to the shutdown of most asylum and the introduction of modern pharmacological treatments, psychological therapies, and social support for persons with mental health complications (NICE 2014).

Pharmacological Treatment/Intervention for Mandy

Antipsychotic medications remain the most widely used treatment for schizophrenia and psychosis symptoms within both community and hospital settings that Mandy can access. The medication option has proven effective for both relapse prevention and acute psychotic treatment over time. Antipsychotic medications ease symptoms associated with schizophrenia and psychosis, such as hallucinations and delusions. The drugs work on brain chemicals, including serotonin and dopamine (Wykes, Huddy, Cellard, McGurk, & Czobor, 2011). However, it is recommended to check the patient’s blood pressure and weight before commencing antipsychotic therapy. Other areas to be monitored include electrocardiogram for haloperidol antipsychotics, electrolytes, liver, blood glucose, and prolactin tests before introducing antipsychotic treatment options (NICE 2014). If such laboratory tests are not feasible, the healthcare provider should investigate the existence of hepatic or renal abnormalities, cardiovascular cases or ask the patients or family members whether drug treatments relating to such medical complications have been prescribed to the patient before (NICE 2014).

However, despite its efficacy, a study has shown that a significant number of service users, about 40%, exhibit a reduced response to the traditional antipsychotic medications and continue to experience severe negative and positive psychotic symptoms. The traditional antipsychotic agents or the first-generation antipsychotics (FGAs) have been linked to severe side effects such as weight gain, sedation, and sexual dysfunction.  This has led to the invention of a better version called the second-generation antipsychotics (SGAs) in response to the severe side effects and limited effectiveness of the FGAs. The SGAs are considered a more effective pharmacological treatment option for psychosis and schizophrenia and produce less disabling side effects. Another advantage linked to second-generation antipsychotics (SGAs) is that they reduce the liability for acute “extrapyramidal symptoms (EPS)” and tardive dyskinesia (Dilbaz, & CONTINUUM Treatment Group 2015).

However, researchers argue that the advantages of SGAs must be poised against other potential side effects, including weight gain and metabolic complications that might lead to risks of the patient developing diabetes and CVD. Researchers argue that the difference between FGAs and SGAs is artificial, and both can work well when adequately administered (Leucht et al., 2013). Being that the treatment is prescribed for a female, in this case, a proper assessment must be done to ensure that the medication does not raise serum prolactin, which is a common problem with many antipsychotic drugs and can translate into other complications such as sexual dysfunction, menstrual abnormalities, and even galactorrhea (Wykes, Huddy, Cellard, McGurk, & Czobor, 2011). Clozapine can be the best option for Mandy’s case. It has been proven that many people who do not respond well to other antipsychotic drugs can improve with clozapine antipsychotics (Morin, & Franck, 2017).

Nevertheless, researchers argue that patients can cope in the long-term minus antipsychotic drugs in fair cases, with both social and neurocognitive functioning able to improve without the medication. Some experts maintain that psychological and psychosocial interventions, if properly administered, can be useful for schizophrenia and psychosis without antipsychotic medication, which has been the first option for decades (Dilbaz, & CONTINUUM Treatment Group 2015).  Even though some researchers have questioned the default reliance on antipsychotic as the first-line treatment for individuals with a mental problem such as schizophrenia, it is still widely accepted in the medical practice that antipsychotics remain an essential component in the treatment of mental illness such as schizophrenia and psychosis (Morin, & Franck, 2017).

Psychological Support/Interventions or Therapies Available for Mandy

Besides the pharmacological treatment, Mandy can also seek various psychological support available within the hospital and community settings for her condition. A recent study and systematic reviews have indicated that psychosocial therapies alongside pharmacological are beneficial to individuals presenting with psychosis and schizophrenia, together with related psychotic illnesses. They can improve the diagnosis and avert further disorder chronicity when offered early enough (Wykes, Huddy, Cellard, McGurk, & Czobor, 2011). Psychological therapies effectively relieve psychotic symptoms and improve the patient’s functioning, making indispensable components of the treatment alternatives available for enhancing the patient’s recovery from psychosis and schizophrenia, and other related psychotic complications. Psychological interventions address varieties of the patient’s health requirements, including relapse, symptoms reductions, and medication adherence, and offer a cost-effective therapy compared to standard treatment (Wykes, Huddy, Cellard, McGurk, & Czobor, 2011). There are five principal categories of psychosocial support that have proven effective in the community-based management of symptoms of schizophrenia and associated psychotic illnesses, with an indication of effectiveness on symptom control and deterioration prevention. The classifications include “cognitive therapy,” “cognitive-behavioral therapy (CBT),” and “cognitive remediation therapy,” family intervention, psycho-education programs, social skills, including coping skills, case management (ACT), and training programs (Morin, & Franck, 2017). There also other approaches, such as psychological formulation and psychodynamic psychotherapy.

Cognitive Behavioral Therapy (CBT)

Cognitive-behavioral therapy (CBT) is regarded as one of the most effective interventions for depressive disorders and proven promising for people with schizophrenia or psychosis whose psychotic symptoms can be controlled through pharmacological methods. Developed in the 1950s, cognitive behavioral therapy is standardized and structured to enhance the patient’s coping capabilities for psychotic symptoms, reevaluating and assessing their perceptions and thought of various experiences (Dilbaz, & CONTINUUM Treatment Group 2015). However, CBT’s efficacy is only realized when the psychoanalyst accepts the patient’s illness and related symptoms and perception of realities and establishes the modalities to apply the “misinterpretations” of facts to help the patients correctly manage their life challenges (Morin, & Franck, 2017). The therapist should encourage the patient to engage in the therapeutic process actively, scrutinizing evidence for and against distressful perceptions, habitual trends of thinking about beliefs and applying personal experience and reasoning to create acceptable alternative and rational explanations, and interpretation for a coping mechanism, self-management, and problems solving concerning the disorders and related symptoms (NICE 2014).

Cognitive Remediation Therapy Support

Mandy can also access cognitive remediation therapy services offered in community and hospital settings to expedite CBT. In response to cognitive impairment in many patients exhibiting psychosis and schizophrenia symptoms, researchers have raised concerns regarding aspects of attention, psychomotor and executive functions, working memory, and other cognitive functioning. The impairments can persevere in psychosis or schizophrenia, limiting the work and psychological functioning of the patient, which in turn reduces the effectiveness of CBT. Cognitive-behavioral therapy requires a high level of attention, self-monitoring, rational judgments, and insights to manage the illness and associated symptoms (Dilbaz, & CONTINUUM Treatment Group 2015). Several cognitive remediation services have emerged since the 1990s, aiming to enhance social cognition and executive function through information reorganization or restructuring alongside environmental aids and other cognitive functioning approaches such as social cognition and neurocognition (Morin, & Franck, 2017).

Neurocognition is the fundamental cognition process that aid in reasoning and thinking and supports memory, attention, and executive functioning capacity. Social cognition, on the other hand, is cognitive abilities supporting interpretation, processing, and regulation of socio-emotional information involved in emotional perception, the theory of mind, perspective-taking, and attribution of social cues or social phenomena (NICE 2014). Other sets of practice principles for schizophrenia and related psychotic are also emerging, including the mental techniques to optimize task completion and cognitive performance, linking cognitive functioning to real-world behaviors, improved development of targeted cognitive capabilities, and incorporation of such cognitive performance with other therapies or treatment options (Wykes, Huddy, Cellard, McGurk, & Czobor, 2011). Social cognition impairment seems to generate adverse effects on community adjustment and interpersonal relationships and hinders functional recovery for psychotic patients (Morin, & Franck, 2017).

Most contemporary control trials adopt only cognitive remediation as an approach to “cognitive rehabilitation” for individuals with schizophrenia symptoms, and the method has indicated its medium-sized impacts of about 0.30–0.48 effect size in improving working memory, processing, executive and attention functioning (Chien, Leung, Yeung, & Wong, 2013). A recent meta-analysis comprising of 26 controlled trials with 1150 patients suggested that cognitive remediation can considerably enhance mental performance up to 0.41 effect size, psychological functioning at 0.36 effect size, and psychotic symptoms at about 0.28 effect size for patients showing schizophrenia symptoms during a short-term of up to 1-2 years follow up (Chien, Leung, Yeung, & Wong, 2013).). Comparable to the results, one more meta-analysis comprising of 40 controlled trials also suggested that cognitive remediation can effective for cognitive functioning when adopted alongside other therapies, including vocational training (Wykes, Huddy, Cellard, McGurk, & Czobor, 2011); hence this study recommend the same for the case of Mandy. Other approaches, such as psycho-education and family interventions, may not be effective for an adult-like Mandy, who also lives alone. Social training, as discussed below, further helps improve Mandy’s condition.

Social Skills Training

Social skills are the individual’s fundamental behaviors. Social skill training is often offered by social workers who focus primarily on the symptoms of psychotic disorder, for instance, the reason for social isolation and withdrawal. The aim is to minimize the symptoms and prevent the likelihood of self-neglect (Mitchell, 2017). Research shows that social skills applied to inappropriate social contexts and ways can improve social competence. Deficiency of social skills is cited as the primary insufficiencies in psychosocial functioning for individuals with psychotic disorders. Lack of social skills proves a hectic social contact with social environments leading to social isolation and withdrawal (Dilbaz, & CONTINUUM Treatment Group 2015). Social skills training models comprises of three primary components, including “social perception (receiving gifts), social cognition (processing skills), and behavioral expression (sending information) skills” (Morin, & Franck, 2017). These skills improve one’s social competency, improving role functioning and social integration (Morin, & Franck, 2017). The training is primarily practiced in groups and aims to improve the patient’s social competence, ranging from communication and interpersonal skills, workplace social skills, community integration, illness management, and daily life activities.

Service Level Interventions For Mandy

Mandy can also seek service-level interventions delivered in community and hospital settings for individuals with schizophrenia and psychosis by health care professionals and social workers. The “balanced care” for the provision of mental health services stresses the significance of attaining equilibrium in all the service facets, including community mental health professionals and outpatient services, community residential care, and other services that support employment. The government facilitated the establishment of an acute psychiatric section in the hospital setting after the asylum’s closure. However, the disintegration of “mental health provider trusts” from the physical health services resulted in the establishment of freestanding inpatient units for mental health, which is readily available in the catchment areas or community settings where they service (NICE 2014).

Such services are beneficial for individuals like Mandy. However, there have been concerns from clinicians and service users concerning admission wards for people with acute mental illnesses. The argument is that such settings do not provide adequate therapeutic interventions and required activities for the patients. As such, efforts have been made to improve the effectiveness and quality of the inpatient care facilities, with several programs such as e Accreditation for “Acute Inpatient Mental Health Services (AIMS)” emerging to facilitate the improvements. There is also the consideration and advocating by voluntary organizations and service users for the residential crisis housings available within the hospital neighborhoods to be used as suitable alternatives to hospital/ward admissions for acute psychotic illness (NICE 2014).   

There are also rehabilitation services that comprise of community worker teams, residential and inpatient elements, which have been time-honored resources for schizophrenia and psychosis for decades. The resources mainly focus on patients with treatment-resistance symptoms alongside acute difficulties in cognitive functioning (NICE 2014). The services might be useful if Mandy’s condition worsens or proves resistance to other treatment options discussed in this paper. Most of these services are designed to meet the psychotic patient’s social needs (Davies 2014). The aim recently has been to design community services that enable the patients to attain self-defined recovery goals.

Conclusion

The primary problem Mandy is currently facing is that of hearing voices, which is disturbing and limiting her ability to lead an everyday life. Mandy’s condition is aggravated by stress and dissatisfaction in her present life, alongside her childhood experiences. A psychiatric assessment can deduce that Mandy is suffering from schizophrenia or psychosis and related psychotic symptoms. This paper explores the various treatment and support options available for Mandy’s condition based on the brief assessment. Mandy can seek pharmacological therapy options, including reliance on antipsychotic medications to ease schizophrenia and psychosis symptoms, such as hallucination and delusions or hearing of voices.

Nevertheless, this study has revealed that despite the efficacy of antipsychotic medications, about 40% exhibits inadequate response to these conventional antipsychotic medications and may continue to experience severe positive and negative psychotic symptoms. Thus, this study recommended that Mandy also seek other psychological interventions such as cognitive-behavioral and redemption therapies and social skills training as advised by her first-life psychiatric professional. There are also other community service level interventions and rehabilitation services that can help the situation become severe. The resources mainly focus on patients with treatment-resistance symptoms alongside acute difficulties in cognitive functioning; therefore, it is recommended when Mandy’s situation worsens or proves resistance to pharmacological and psychological approaches.

References

Chien, W. T., Leung, S. F., Yeung, F. K., & Wong, W. K. (2013). Current approaches to treatments for schizophrenia spectrum disorders, part II: psychosocial interventions and patient-focused perspectives in psychiatric care. Neuropsychiatric disease and treatment, 9, 1463.

Davies, J. (2014) Cracked: Why Psychiatry Is Doing More Harm Than Good, London, Icon.

Dilbaz, N., & CONTINUUM Treatment Group. (, 2015). New targets for the management of schizophrenia. Klinik Psikofarmakoloji Bülteni-Bulletin of Clinical Psychopharmacology, 25(4), 407-428.