Nursing a patient with a severe psychotic illness for general nurses and healthcare officers

Nursesplayacentralroleintheassessmentandtreatmentofpatientswithsevere,psychoticmental illnesses.Nursingsuchpatientsisaskilledjobthatrequiresspecialtraining.Sometimes,generalnurses orhealthcareofficerswithoutmentalhealthtrainingmayaugmentthecareprovidedbymentalhealth nurses.Thissectionprovidesinformationtohelpthemtodothat.Itcoverstwotopics. Informationaboutpsychoticillness. Whatageneralistnursecandotocontributetoassessmentandtreatment. Itdoesnotcoverspecialisttopicssuchashowtoassesshallucinationsanddelusions. Information about psychosis

What is psychosis?
Thewordpsychosisisusedtodescribeabroadrangeofmentaldisordersthataffectthemind,where therehasbeensomelossofcontactwithreality.Thesetypesofdisorderscanvarygreatly,though certaintypesofsymptomsarecharacteristic.Theyincludeunusualandoftenextremelydistressing experiencessuchasthefollowing. Disturbancesofthinking:thoughtsbecomeconfusedandmayseemtospeeduporslowdown. Sentencesareunclearordonotmakesense.Patientsmayfeelasiftheirthoughtsarebeingputinto theirheadandarenottheirownthoughts.Theymayhavedifficultyconcentrating,followinga conversationorrememberingthings.Theymaythenappeartobeunresponsiveoruncooperative. Delusions:falsebeliefsthatseemrealtothepatientandarenotamenabletologicalargument.They areoftenveryfrightening.Forexample,apersonmaybelievethattheirfoodisbeingpoisoned. Commonthemesfordelusionalbeliefsarepersecution,punishment,grandiosityandreligiosity.For example,someoneacutelyillmaybelievethatheisJesus. Hallucinations:patientsees,hears,feels,smellsortastessomethingthatisnotactuallythere.For example,theymayhearvoicesthatnooneelsecanhear.Foodmaytasteorsmellasifitisbador poisoned.Hearingvoicesisaverycommonsymptomofschizophrenia.Thehallucinationscanrange fromoccasionalvoicesthroughtoanalmostconstantbarrageofderogatorycommentsfromalarge numberofdifferentvoices. Changedfeelings:patientsmayfeelstrangeandcutofffromtheworld.Moodswingsarecommon andpatientsmayfeelunusuallyexcitedordepressed.Theiremotionsmayseemdampenedthey feellessthantheyusedtoorshowlessemotiontothosearoundthem.

Different types of psychotic disorder

Therearedifferenttypesofpsychoticillness.Theseincludethefollowing. Substanceinducedpsychosis:useof,orwithdrawalfrom,alcoholordrugsmaybeassociatedwith theappearanceofpsychoticsymptoms.Sometimesthesymptomsremitastheeffectsofthe substanceswearoff.Sometimestheillnesslastslonger.Itispossibleforapatienttobothhaveamore longtermpsychoticillnessandtomisusesubstances.Itisnotpossibletotellfromthesymptoms alonewhethersomeonehasasubstanceinducedpsychosisorwhethertheyhaveanotherpsychotic disorder.Itisamistaketothinkthatbecauseaprisonerisadrugusertheycannotalsohaveasevere psychoticillnesssuchasschizophrenia. Briefreactivepsychosis:psychoticsymptomsarisesuddenlyinresponsetoamajorstressinthe patientslife.Thepatientmakesaquickrecoveryinafewdays. Organicpsychosis:physicalinjuryorillness,suchasabraininjury,encephalitis,AIDSoratumour, maycausepsychoticsymptoms. Schizophrenia:psychoticillnessinwhichthesymptomshavebeencontinuingforatleast6months. Thesymptomsandthelengthoftheillnessvary. Bipolardisorder(manicdepression)andpsychoticdepression:psychoticsymptomsappearaspart ofamoregeneraldisturbanceofmood.Whenpsychoticsymptomsarepresent,theytendtofitin withthepersonsmood.Forexample,someonewhoisdepressedmayhearvoicestellingthemthey shouldkillthemselves.Someonewhoisunusuallyexcited(manic)maybelievethattheyhavespecial powersandcanperformamazingfeats.

What causes psychosis?

Schizophreniaisprobablycausedbyacombinationofbiologicalfactors(suchasafamilyhistoryof schizophrenia)thatcreateavulnerabilitytoexperiencingpsychoticsymptoms.Thesymptomsoften

emergeinresponsetostress(egbreakdownofarelationship,beingheldinsolitaryconfinement, bullying),drugabuseorsocialchangesinvulnerableindividuals.Thistheoryofcausationisknownas thestressvulnerabilitymodel.Ithelpstoexplainwhypsychosisisusuallyanepisodicproblem,with episodestriggeredbystressandpatientsoftenquitewellbetweenepisodes.Italsohelpstoguide management.Internationalstudiesshowthatonceapersonhasschizophrenia,theenvironmentin whichhe/shelivescanhelpthemtostaywellorcanmakethemworse.Inacalmenvironmentandone wherepeopleprovideplentyofsupportandencouragement,thosewithschizophreniawillsufferfewer psychoticepisodesthaniftheyaresurroundedbypeoplewhopush,frightenorcriticisethem.

Prognosis: do people get better?

Schizophreniausuallybeginsinearlyadultlifebutmayoccuratanytimeinanindividualslife.Those whodevelopschizophreniaataveryearlyagedonottendtodoaswellasthosewhoseillnessbeginsin middleoroldage.Althoughforsomeschizophreniawillbealifelongconcern,othersexperienceonly oneepisodeoftheillnessandneverhaveafurtherepisode.Generally,20%ofpeoplerecover completely,35%arestableforlongperiodsbuthavesomefurtherepisodesofpsychosis,and45% experiencelongtermproblemsrequiringcontinuingcare.Onequarterofthelattergroupdeteriorate moreseverelyandrapidlyandneedveryhighlevelsofcareandsupport. Whensomeoneisinaverydistressed,acutelyillstate,itcanbehardtobelievethattheywilleverget better.Realistichopeisoneofthemostimportanttreatmentsanurseorhealthcareofficerhastooffer.

What are the treatments?

Assessment:firststageoftreatmentinvolvesassessment,usuallyoversometime.Mentalhealth

specialistsneedtodevelopanunderstandingwiththepatientofhowandwhythesesymptomsaffect them.Arangeofmeasuresmayformpartoftheassessment,egtheDelusionRatingScaleandthe BeliefaboutVoicesquestionnaire. Medication:alongwithotherformsoftreatment,medicationplaysafundamentalroleinrecovery fromapsychoticepisodeandinthepreventionoffutureepisodes.Themonitoringofsideeffectsis criticaltoavoidorreducedistressingsideeffectsthatcanleadtoapatientbeingunwillingtoaccept themedicationcentraltotheirrecovery.Informationaboutthemedicationsusedinmentalillnessis givenonpage166. Counsellingandpsychologicaltherapy:havingsomeonetotalktoisanimportantpartoftreatment. Apersonwithacutepsychoticsymptomsmayneedtoknowthatthereissomeonewhocan understandsomethingabouttheirexperienceandprovidereassurancethattheywillrecover.As recoveryprogresses,differentformsofpsychologicaltherapycan: helpthepatientandthosecaringforthem(onordinarylocation)learnhowtokeepstresslevels lowinordertopreventfurtherepisodes helpthepatientandthosecaringforthem(onordinarylocation)recogniseearlywarningsigns thatafurtherpsychoticepisodeisdevelopingand helpthepatientlearnwaysofreducingtheimpactofhallucinationsanddelusions. Practicalassistance:treatmentoftenalsoinvolvesassistancewithemployment,education,finances andaccommodation. What the generalist nurse or healthcare officer can do

Communication (engagement)1

Inorderforthehealthcareteamtohelpthepatient,thepatienthastofeelthattheteamisontheirside andbepreparedtocommunicateand,atleasttosomeextent,tocooperatewiththeteam.Atrusting relationshipwithanymemberofthehealthcareteamisthereforeimportanttothesuccessofthe treatment.Buildingsucharelationshipisespeciallyhardwithapatientwhoispsychoticas,atleastin theacutestage,theymaybelievethatyouintendtoharmthem.Whenyoutalktothepatient,itislikely thatyouwillhavetoadaptyourusualcommunicationstyleasthepatientsmemory,concentrationand tolerancelevelsmayallbereduced. Talkingwithsomeonewithaseverementalillness: Neverleavesomeonewhoismentallyilltoguessyourintentionsortheintentionsofother membersofthehealthcareteam.Theirimaginationwillrunriot.Alwaysexplainwhyyou,thedoctor orotherpersonwantstotalkwiththem. Trytoensurethattheenvironmentiscomfortableandsafeforbothyouandthepatient.Askwhere inthehealthcarecentrethepatientfeelssafe/OKtotalk. Rememberthatsocialinteractioncanbeverystressfulforthepatientandbepreparedto acknowledgethis:Icanseehowhardthisisforyou.Iappreciateyoumakingtheefforttotalktome. Bewarmandfriendlybutalsopreparedtospendtimeinsilence.

Alwaysbeawareofculturalissues.Ifyouarenotsure,ask.Findingoutasmuchasyoucanabout thepatientsculturewillhelpcommunication. Talkingwithsomeonewhoishearingvoices.Ifyouarenotsuresomeoneishearingvoicesatthis particulartime,askthem.Iftheyare,dothefollowing: Acknowledgethedifficultyanddistressthatvoicescause.Forexample,Itmustbereallydifficult foryouhavingthisconversation.Ireallyappreciateyoumakingtheeffort. Donotchallengethefactthatthepatientcanhearvoices.Theyarerealtothepatient.However, youcansayinagentleandmatteroffactwaysomethinglike,Itsyourbrainplayingatrickonyou justnow. Talkclearlyandslowlyifnecessaryandbepreparedtorepeatquestions. Bepreparedtotakelongerevenforasimplematter. Ifsomeoneisobviouslyindistress,askthemiftheyhavehadenough.Bepreparedtocomeback later. Talkingwithsomeonewhomentionstheirdelusionalbeliefs: Showsomeunderstandingofthepersonsfeelings,egItmustbereallyscarytothinkthat someoneelseiscontrollingyourthoughts. Donotargueaboutthestrangeideasbutdonotpretendtoagreewiththemeither.Focusinstead onhowthedelusionsmakethemfeelandthenchangethesubjecttosomethingneutralorpleasantin reallife(egwhatisfor dinner?). Iftheconversationisdistressingtothepatientortoyou,itisOKtosay,Illtalktoyoulaterwhen yourefeelingabitbetter. Relatingtosomeonewhoiswithdrawnorisolated: Bepreparedtositwiththepatientinsilence. Doingpracticaltasksclosetothepatientcanbecomforting.Sharingactivitieswithouttalkingcan alsobehelpful. Gentlyencourageotheractivitieswhicharenottoodemanding(egwatchingtelevision,washing dishes,playingaboardgame). Bepreparedtokeeptrying.Itcantakealongtimeforsomepeopletorespond. Talkingwithsomeonewhoisangryoraggressive.Peoplewithschizophreniaareusuallyshyand withdrawn.However,theymayalsobecomeaggressive,especiallywhentheyareexperiencingfear orparanoia(feelingthattheyarebeingpersecutedandthatotherpeopleareouttogetthem)or voices(voicescan,rarely,commandapersontoinjureothers). InformationaboutdealingwithaggressioncanbefoundinAggression(page282).Toreducepatient fearsandthepotentialforaggression,itmaybehelpfultodothefollowing: Givethepatientspace.Donotcrowdthem. Informthepatientaboutwhatyouaredoingandintendtodo. Tellthepatientthatyoudonotmeanthemanyharm. Talkcalmlyandevenly. Talktothepatientinaquietenvironment. Continuallyreassurethem. Keepyourhandsinview. Keepyourmovementstoaminimum. Askthemwhytheyareupset.

Observation: contribution to assessment

Nursesandhealthcareofficersmayspendlongperiodswithpatients.Yourobservationsofthepatients behaviourareaveryvaluablepartoftheassessment.Generalinformationaboutconducting observationsisprovidedinObservation(page200).Inpsychoticillness,helpfulobservationsinclude thefrequency,intensityanddurationofpositivesymptomsandtheextentofnegativesymptoms. Positivesymptomsinclude: Negativesymptomsinclude:

Hallucinations. Delusions. Thoughtdisorder. Paranoia.

Lackofmotivation. Socialwithdrawal. Emotionalwithdrawal. Difficultyinformingrelationships. Lackofspontaneity.

Makeyourobservationsasconcreteandobjectiveaspossible,egSpentallmorninginbed.Appearedto watchtelevisioninafternoonbutshowednoreactionstotheprogrammesortochangesofchannelby others.Unresponsivetoeffortstoholdconversation(ratherthanwithdrawn).

Reassure, encourage and support the positives

Peoplewithapsychoticillnessarelikelytofeelconfused,distressed,afraidandlackinginself confidence,bothduringtheacutephaseandforalongtimeafterwards.Theillnesshasprobablycaused themtolosecontroloftheirthoughtsandtofeeloverwhelmedbytheworldaroundthem.Asthey recover,itiscommonforpatientsto: sleepforlonghourseverynight(orduringtheday)for612monthsafterthepsychoticepisode feeltheneedtobequietandalonemoreoftenthanotherpeopleand beinactiveandfeelthattheycannotordonotwanttodomuch. Itishelpfultoexplaintothepatientwhatishappeningtothem,egthatpsychoticsymptomsusually appearasaresponsetoseverestresses(seeWhatcausespsychosisabove)andthatadditionalsleepand inactivityisthebodysnaturalwayofslowingdowntoallowthebraintorecoverfollowingtheshockof anacuteepisode. Itisalsohelpful,asthepatientrecoversfromthemostacutestageoftheillness,toencouragethemto resumeactivitiesgraduallythattheyhavebeenabletodoandhaveenjoyedinthepast.Encouragethe patienttohelpwithsimplejobsaroundthehealthcarecentreortochatwithyouortojoininanyartor othertherapeuticactivityonoffer.Ifthepatientrefuses,donotpressurethembutmakeitclearthat theyarewelcometocomewhentheyfeelabletojoinin.Makeitclearthattheyarewelcomesimplyto sitinthecompanyofothersandwatchorlistentopeoplewithoutjoininginmoreactively.Youmay findthatthepatientlikestolistentoloudmusicalotofthetime.Thismaybeawayofdrowningout distressingvoicesorthoughts.EarphonesoraWalkmanmaybehelpful. Mostimportantly,itishelpfultorelatetothepatientasahumanbeingwhohasinterestsand strengthsseparatefromhis/herpsychoticsymptomsorlackofthem.Thismaybecrucialinrebuilding someselfesteemandhopeforthefuture.Findoutwhatthepatientsinterestsareand,ifyoucan, discussthemwiththepatient.Ifthepatienthascontactwithfamilymemberswhoaresupportive,tryto arrangeavisit.Itmaybeveryhelpfulforthefamilymemberstohaveinformationaboutpsychosis.This canbeprovidedbyanorganisationsuchastheNationalSchizophreniaFellowship(fordetails,see Resourcedirectory,page316).

Reduce stress and conflict

Becauseenvironmentalstressplayssuchaprominentpartintriggeringepisodesofpsychosis,reducing suchenvironmentalstressisanimportantpartofbothtreatmentandprevention.Theparticularkindof stressthatstudieshavefoundtobedetrimentaltopatientswithschizophreniaconsistsofhighlevelsof expressedemotion.Thismeans: hostility:notonlyjustbullyingorphysicalaggression,butalsoangryshouting emotionaloverinvolvement,egCanyoutidyyourcellforme?and criticism,egcallingapatientlazy,blaminghim/herforbeinguncooperative. StayingcalmandusingthecommunicationtipsinCommunication/engagementabovewillbehelpful. Ensuringthatthepatientsareinanenvironmentsafefrombullyingisalsoimportant.Ifthepatient returnstonormallocationwhentheacuteepisodeisover,residentialmanagersshouldbeawarethat thewaythepatientistreatedbystaffandprisonerswillsignificantlyaffectthelikelihoodofrelapse. Additionalpatienceandgivingleewaymayberequired.

Look out for depression and suicidal thoughts

Peoplewhohavepsychoticillnessesareatsignificantlyhigherriskofdepressionandsuicide.Theytend tohavelowselfesteem,tofeelhopelessabouttheirlives,tomisusedrugsandalcohol,tolosetheir socialroleandbeunabletoattaintheirpersonalgoals.Inaddition,somemayhearvoicestelling themselvestokillthemselves. Ifthepatientexpressesdepressedorsuicidalthoughtstoyou,dothefollowing. Listentotheirfeelings,butalsopointoutthathelpisavailable. Expressappreciationofthepatientsfeelingsandthefactthathe/sheconfidedinyou. Letthedoctorandmentalhealthnurseknowandconsideropeninga2052SHform(inScotland,an ActtoCareform). Distractthepatientbyinvolvinghim/herinpleasant,lowkeyactivities.

 Helpthemtobewithsomeonebywhomtheyfeelaccepted. Letthepatientknowthatyouacceptandcareaboutthem. Considerwhetheranystressorscanberemovedthatmightbedepressingthepatient(egworries

aboutgoingbacktoalocationonwhichhehadbeenbullied).

Medication
Informationonpsychotropicdrugsisprovidedonpage188.Ifyoubecomeawarethatapatientisnot takingthemedication,dothefollowing: Remindthemcalmlythatthemedicationhelpstokeepthemwell. Askiftheyarehavinganysideeffects. Letthedoctorormentalhealthnurseknowthatthepatientisrefusingtotakethemedication.
1 ThesectiononcommunicationwasadaptedfromTheguidetocommunicatingwithpeoplewhohaveserious mentalhealthproblems,developedbyKatieGloverwhenshewasatSTART,aHomelessMentallyIllInitiative ProjectinLondon.

Medications used for mental-health problems

Information for non-specialist nurses

Generalnursesmaybeinvolvedinadministeringpsychotropicmedication.Thissectionisabriefguide tothemaintypesofdrugsusedtotreatmentaldisorders.Theaimistohelpyouanswersimple questionsthatpatientsmayask,andtoknowwhattodoifthepatientdoesnotturnuptocollecttheir medicine.Furthertrainingisneededtohelpyourecogniseanddealwiththesideeffectsofmedication. Thethingstorememberarethefollowing: Apatientcanonlybegivenmedicationtheyhaveagreedtotake(consent). Consentmustbevoluntaryandreflectacontinuingagreementtotakethemedication. Patientscanchangetheirmindabouttakingmedication. Wheninformationisgiventoapatientabouttheirillnessandmedication,itcanincreasethechance ofconsentbeinggiven. Ifapatientrefusestotakethemedication,youshouldrecordtheirviewsinthenotesandreportthe facttotheprescribingdoctor. Anxiety and insomnia

Benzodiazepines What are they?

Benzodiazepinesaredrugsusedprimarilytotreatsymptomsofthefollowing. Severeanxiety,egtension,feelingshaky,sweatingandadifficultyinthinkingstraight.Thedrugs, knownasanxiolyticsand(misleadingly)minortranquillisers,includediazepam(Valium),lorazepam (Ativan),oxazepam(Serenid)andchlordiazepoxide(Librium). Shorttermproblemswithsleeping.Drugsknownashypnoticsincludeloprazolam,nitrazepam (Mogadon)andtemazepam(Normison). Benzodiazepinesalsohavemusclerelaxingpropertiesandsome(egdiazepam)canhelpthefollowing: Epilepsy:particularlystatusepilepticus. Symptomsofalcoholwithdrawal(usuallychlordiazepoxide).Whensomeonehasbeenheavily dependentuponalcohol,givingbenzodiazepinesduringwithdrawalmayhelppreventveryserious, evenlifethreateningsymptomssuchasdeliriumtremens.

Side-effects
Commonsideeffects Drowsiness,sleepinessandaninabilitytoconcentrateduringtheday. Rarebutimportantsideeffects Patientbecomesaggressive,excitable,talkativeordisinhibited.Askthedoctortoreviewthe medication. Rash:ifthisoccurs,patientsshouldstopthedrugandseethedoctor.

When are they not helpful?

Benzodiazepinesarenotidealforthetreatmentofanxietyandinsomniabecausetheyonlygive symptomaticrelief,donottreattheunderlyingillnessandareaddictive. Theyshouldnotbetakenregularlyformorethan46weeks.Takingthemonceperdayorevery otherday(forinsomnia)orirregularly,egfor1or2weeksforpanicattacks,reduces,butdoesnot eliminate,theriskofaddiction(formoreefficaciousandlongertermtreatments,seetheguidelineson Sleepproblems,PanicandGeneralisedanxietydisorder,pages91,67and64).Benzodiazepines shouldbeavoidedwhereverpossibleduringpregnancy,childbirthandbreastfeeding.Theycansedate thebabyandcausebreathingproblems.Theyshouldnotbeusedroutinelytodealwithsuddenstress (egbereavement,imprisonment)(seetheguidelinesonBereavementandAdjustmentdisorders,pages 23and15).

Important notes about benzodiazepines

General

 Theyarecommonlytradedillicitlyonthestreetandinprison.Ensurethatthedruggoesto,andis

takenby,thepersonforwhomitisprescribed. Ifapatientmissesadose,donotgivetwoormoredosestogethernexttime. Theyaddtotheeffectofalcohol.Advisepatientswhomaybereleasedthatalcoholisbestavoided. Manypeoplebecomeaddictedtobenzodiazepinesbecauseoflegalprescribingbytheirdoctor. Withdrawal Benzodiazepinesshouldnotbestoppedsuddenlyiftheyhavebeentakenregularlyformorethan46 weeks. Withdrawalshouldnevertakelessthan68weeksandoftenmuchlonger Withdrawalsymptomscanincludeanxiety,tension,panicattacks,poorconcentration,difficultyin sleeping,nausea,trembling,palpitations,sweating,andpainsandstiffnessintheface,headandneck. Theriskofsuicideandselfinjuryincreasesduringwithdrawalandtheregularmonitoringofthe suicideriskisrequired. Duringwithdrawal(especiallyifitoccursquickly),thepatientmaybehaveunpredictablyandposea managementproblem.Adviseofficersthatthismaybepartofthewithdrawalsyndrome.They shoulddealwiththepatientascalmlyastheycan.Itmaybepossibletopostponeadjudicationsuntil afterthewithdrawaliscompletesothatanyimprovedbehaviourcanbetakenintoaccount. Individualswithdrawingfrombenzodiazepinesmaybenefitfromhelpwithanxietycopingskills. Helplinesandorganisationsprovidingsupportforthosewishingtowithdrawfrombenzodiazepinesis providedbelow. Resources for people addicted to tranquillisers BattleAgainstTranquillisers(BAT):01179663629(helpline:MondaySunday, 9am8pm) POBox658,BristolBS991XP (Counsellingandsupportforthoseconsideringstoppingtheirtranquillisersandthosewhohave succeededindoingso) CITA(CouncilforInvoluntaryTranquilliserAddiction):01519490102(MondayFriday,10am1 pm) CavendishHouse,BrightonRoad,Waterloo,Liverpool (Confidentialadviceandsupport) Drugline:02086924975 (Adviceandcounsellingfordrugrelatedproblems) HelpingYouCope:AGuidetoStartingandStoppingTranquillisersandSleepingTablets.Availablefrom: MentalHealthFoundation,UKOffice,20/21CornwallTerrace,LondonNW14QL.Tel:0207535 7400;Fax:02075357474;Email:mhf@mhf.org.uk;URL:http://www.mentalhealth.org.uk MakingSenseofTreatmentsandDrugs:MinorTranquillisers.Availablefrom:MIND,1519Broadway, LondonE154BQ.Tel:02085192122;Fax:02085221725;Email:contact@mind.org.uk;URL: http://www.mind.org.uk/

-Blockers What are they?

Blockersincludeoxprenolol(Trasicor)andpropranolol(Inderal).Inlowerdoses,theycanhelptreat thephysicalsymptomsofthefollowing. Anxiety,egpalpitations,sweating,shakiness.Theydonotaffectthepsychologicalsymptoms(eg worry,tensionandfear). Heartconditionssuchashypertension(highbloodpressure),anginaandarrhythmias.

Side-effects
Commonsideeffects Fatigue,coldextremities. Rarebutimportantsideeffects

Rashoritchyskin,dryeyes,veryslowpulse.Advisethepatienttoconsultthedoctorimmediately.

Important notes about -blockers

Peoplewithasthmashouldnottakethem. Thereisnoevidencethattheyareaddictivebuttheyshouldbestoppedgraduallybecauseofthe likelihoodofreboundtachycardia. Ifthepatientmissesadose,donotgivetwoormoredosesatonce.Thismaycausemoresideeffects.

Hypnotics What are they?

Hypnoticsareusedasashorttermtreatmentforinsomnia. Nonbenzodiazepinehypnoticsincludechloralhydrate,chloralbetaine(Welldorm),clomethiazole (Heminevrin),promethazine(Phenergan),diphenhydramine(Nytol),zaleplon(Sonata)andzopicline (Zimovane). Promethazineanddiphenhydramineareantihistamines.Chlormethiazole(Heminevrin)canhelp agitationandrestlessnessaswellasalcoholwithdrawalsymptoms.

Side-effects
Commonsideeffects Allhypnotics:drowsiness,dizziness,reducedreactiontimesduringtheday. Rarebutimportantsideeffects Chloral:rashes/blotches,wheeziness(especiallyifthepatienthasasthma). Antihistamines:wheeziness(especiallyifthepatienthasasthma),palpitations/fastheartbeat. Ifanyoftheaboveoccur,advisethepatienttostopthedrugandconsultthedoctorimmediately. Importantnotesabouthypnotics Theyarecommonlytradedillicitlyonthestreetandinprison.Ensurethatthedruggoesto,andis takenby,thepersonforwhomitisprescribed. Theymaycauseaddictioniftakenregularlyforlongerthan46weeksandshouldbetakeninaslow adoseaspossiblefortheshortesttimepossible.Takingthemonlywhenrequiredoreveryfewdays (egonalternatenights)canbeausefulwaytousethedrugssafely. Itisrecommendedthatchlormethiazoleistakenfornolongerthan9daysifusedtohelpalcohol withdrawal. Ifdependenceoccurs,withdrawalsymptomscanincludeanxiety,tension,poorconcentration, difficultyinsleeping(reboundinsomnia),palpitationsandsweating. Antidepressants

What are they?

Antidepressantsareusedtoimprovemoodinpeoplewhoarefeelinglowordepressed.Certain antidepressantsmayalsobeusedtohelpthesymptomsofpanicdisorder,obsessivecompulsive disorder,socialphobia,bulimianervosa,posttraumaticstressdisorder(PTSD)andchronicpain syndrome.Allthesedrugsseemtobeequallyeffectivefordepressionattheproperdose,buttheyhave differentsideeffects.Ifonedrugdoesnotsuitapatient,anothermaybetried.Therearethreemain typesofantidepressants. Tricyclics(TCAs):includeamitriptyline(Typtizol),amoxapine(Asendis),dothiepinordosulepin (Prothiaden),Imipramine(Tofranil)andlofepramine(Gamanil). Selectiveserotoninreuptakeinhibitors(SSRIs):includecitalopram(Cipramil),fluoxetine(Prozac), fluvoxamine(Faverin),paroxetine(Seroxat)andsertraline(Lustral). Irreversiblemonoamineoxidaseinhibitors(MAOIs):includeisocarboxazide(Marplan),phenelzine (Nardil)andtranylcypromine(Parnate).AspecialkindofMAOIisknownasareversibleinhibitorof monoamineoxidasetypeA(RIMAs).Theseincludemoclobemide(Manerix). Thereare,inaddition,anumberofotherantidepressants,suchasvenlafaxine(Efexor),mirtazapine, nefazodone,reboxetineandtrazodone.

Side-effects

Commonsideeffects TCAs:sedation,drymouth,blurredvision,weightgain,constipation,sweating. SSRIs:insomnia,stomachupsets,sexualdysfunction. MAOIs:blurredvision,dizziness,drowsiness,drymouth,constipation. RIMAs:drymouth,nausea,headache,dizziness,insomnia. Rarebutimportantsideeffects TCAs:skinrashes:stopmedicationandconsultthedoctorimmediately. SSRIs:skinrashes:stopmedicationandconsultthedoctorimmediately. MAOIs:urineretention:refertothedoctorimmediately.Sweating,blurredvision,skinrashes, headache:stopmedicationandconsultthedoctorimmediately. Importantnotesaboutantidepressants Ifapatientmissesadose,seekthemoutandaskhowtheyare.Askthestafftoo.Itispossiblethatthe patienthasnotcometocollectthemedicationbecausehe/shehasbecomemoredepressed,with increasedlethargy,hopelessnessandanincreasedriskofsuicide. Ifapatientmissesadose,donotgivetwoormoredosesnexttimeasthismayincreasesideeffects. Theymayrequireatleast2weeksbeforetheirmoodstartstoliftand6weeksbeforeafulleffectis achieved.Somechanges(egincreasedappetite,energylevels)mayoccurbeforethis.Informthe patientaboutthislagineffectiveness.Theriskofsuicidemayriseduringthistime.Careful monitoringisrequired. WithTCAs,overdoseattemptsareseriousandoftenfatalduetocardiaccomplications.Thesymptomsof overdoseinclude:agitation,confusion,drowsiness,difficultyinbreathing,convulsions,bowelandbladder paralysis,dilatedpupils,anddisturbanceswiththeregulationofbloodpressureandtemperature. Tranylcypromine(aMAOI)byvirtueofitsamphetaminelikepropertieshasahighabusepotential. Takeextracaretoensurethatthedrugisgivento,andtakenby,therightpatient. WithMAOIs,dietaryrestrictionsarenecessarytopreventatyramineinducedandpotentiallyfatal hypertensivecrisis.Tyramineisfoundinmanycommonfoods.Patientsshouldnottakeanyother drugatall(includingoverthecountercoughandcoldremedies)withoutconsultingadoctor.Ifa throbbingheadachedevelops,medicalattentionshouldbesoughtimmediately. Mostpeoplemayneedtocontinuetakingantidepressantsforatleast4monthsandsomemayneedto continuefor12monthsormore,especiallyiftheyhavebeendepressedmorethanonce,toreducethe chanceofrelapse. Antidepressantsshouldnotbestoppedsuddenly,evenifthepatientfeelsbetter.Theirdepression mayreturn.Inaddition,theymayexperiencediscontinuationsymptoms.Atworst,thesecould includeheadache,restlessness,diarrhoea,nausea,flulikesymptoms,lethargy,abdominalcramps, sleepdisturbanceandmildmovementdisorders.Theseareusuallyshortlivedandcanevenoccur withmisseddoses. Despitethediscontinuationsymptoms,antidepressantsarenotaddictivebecausetheydonot producecravingforthedrug,ortolerance(ieneedingmoreofthedrugtogetthesameeffect). Antipsychotic medication

What is it for?
Antipsychoticdrugsarecalledneurolepticsor,misleadingly,majortranquillisers.Theyareusuallyused onlyforthetreatmentofseverepsychoticillnessessuchasschizophrenia,maniaandmajordepression withpsychoticfeatures.Theirsideeffectsarecommonandoftenserious.Theycanalsobeusedtohelp manageconfusion,dementia,behaviourproblemsandpersonalitydisorders,or,insmallerdoses,to helptreatanxiety,tensionandagitation.Theyhaveaninitial,rapid,tranquillising(calming)effect. Theireffectonpsychoticsymptoms,suchasdelusionsandhallucinations,maynotappearforseveral weeks.Therearetwomaingroupsofdrugs. Typicalorclassicalantipsychotics:includelowpotencydrugs,suchaschlorpromazine(Largactil), whichareusedinhundredsofmilligramsperday,andhighpotencydrugs,suchashaloperidol (Serenace)andfluphenazine(Moditen),whichareusedintensofmilligramsperday. Atypicalantipsychotics:suchasrisperidone(Risperdal),olanzapine(Zyprexa)andclozapine (Clozaril).Clozapineisanatypicalantipsychoticthathas,todate,auniqueeffectivenesswith patientswhohavenotimprovedwithotherantipsychotics(drugresistantschizophrenia).

Sometypicalantipsychoticsareavailableaslongactingdepotinjections,suchasfluphenazine decanoate(Modecate)andhaloperidoldecanoate(Haldol).Antipsychoticdrugshavedifferentside effectstoeachother.Ifonedrugdoesnotsuitapatient,anothermaybetried.

Side-effects
Thereisawiderangeofsideeffects.Manyarecommon.Theycancausesignificantimpairmentin functioningandmaybethereasonwhysomepeoplestoptakingtheirmedication.Theyoccurmost commonlywiththehighpotencytypicalantipsychotics.Withappropriateadviceandmanagement, sideeffectscanbeminimised.Ifapatientisdistressedbysideeffects,advisethemtohaveadiscussion withthedoctorormentalhealthnurse. Commonsideeffects Constipation,dizziness,drowsiness,drymouth,appetiteincrease,blurredvision.Movement disorders,knownasextrapyramidalsideeffects,includeshakyhands,feelingshaky,involuntary movementsoftheface,neck,eyesandtongue.Also,akathisia(acutefeelingofrestlessnessinthelegs, constantpacing). Rarebutimportantsideeffects Feverandmusclestiffnesscouldbeneurolepticmalignantsyndrome,whichisrarebutpotentially fatal.Stopmedicationandcallthedoctorurgently.Thepatientshouldbecooled,andthebodyfluids andserumelectrolytesmonitored.Anticholinergicmedicationwillbeneeded. Skinrashes:stopmedicationandconsultthedoctorimmediately.

Depot injections
Itissometimesnecessaryorhelpfulforantipsychoticstobegivenasdepotinjections.Adepotinjection isalongactinginjectionusuallygivenintoabuttock.Theinjectionreleasesdrugoverseveralweeks,so thepatientdoesnothavetoremembertotaketabletsatregulartimeseachday.Depotinjectionsareno moreorlesseffectivethantabletsorcapsules.Theyshouldonlybegivenwhereessential,astheyare painfultoreceive.Theadministrationofdepotinjectionsshouldbeprecededbyanassessmentofthe patientsmentalstateandgeneralphysicalhealth,includingsideeffects.

Important notes about antipsychotic medication

Itisessentialthatmedicationistakenregularlytoavoidarecurrenceofpsychoticsymptoms.If

patientsfailtoturnupfortheirmedication,makecontactwiththemtoassesswhytheyhavenot takentheirmedication.Reportthistotheprescribingdoctorormentalhealthnurse. Sedativeantipsychoticsmayimpairmentalabilities.Ifalertnessisimpaired,advisethepatientto avoidoperatingmachineryordriving. Remindpatients,especiallyanyonewhoistakingclozapine(Clozaril),toreportthesudden appearanceofsignsofinfection(sorethroat,fever).Acompletebloodcountshouldbedone immediatelytocheckforthedevelopmentofagranulocytosis. Anticholinergic medication

What are they for?

Anticholinergicmedicationincludesprocyclidine(Kemadrin)andorphenadrine(Disipal).Thesedrugs areusedtoreducesomeoftheextrapyramidalsideeffectsofantipsychoticmedication.Acutedystonia andParkinsonismrespondquitewell,tremorrespondslesswell,akathisiarespondspoorlyandtardive dyskinesiacanbemadeworsebythedrugs.Thesedrugsshouldnotbeprescribedroutinelyforall peopletakingantipsychoticmedication,butonlyaftersymptomsarise.Withdrawalofanticholinergic drugsshouldbeattemptedafter2or3monthswithoutsymptoms,asthedrugsareliabletomisuseand mayimpairmemory.

Side-effects
Commonsideeffects Drymouth,constipation,blurredvision. Rarebutimportantsideeffects Urineretention:contactthedoctor.

Important notes about anticholinergic medication

 Patientsmaytradethemandmaytrytoobtainanextradose. Drugshaveamoodelevatingeffectand,whentakenontheirown,intheabsenceofantipsychotic Takestepstoensurethatthedrugisgiventoandtakenbytheindividualforwhomitisprescribed.

Mood stabilisers medication,mayalsocausemusclestobecomestiffor,ifenoughistaken,togointospasm.

What are they for?

Moodstabilisersaredrugsusedtohelppreventmoodswings(feelinghighorlow)inpeoplewho sufferfromabipolarillness(sometimescalledmanicdepression).Theyincludelithiumcarbonate (Camcolit),sodiumvalproate(Epilim)andcarbamazepine(Tegretol).Lithiumisalsousedinsevere, recurrentdepressiveillnessandinaggression.Carbamazepineandsodiumvalproatearealsousedto helpcontrolepilepsy.Carbamazepineisalsousedtorelievethesymptomsoftrigeminalneuralgia(a painfulconditionoftheface)andinanumberofotherillnessessuchasalcoholwithdrawaloralcohol dependence,schizophreniaandwithdrawalfrombenzodiazepines.

Side-effects
Commonsideeffects Lithium:nausea,diarrhoea,metallictasteinthemouth,weightgain,increasedthirst,difficultyin concentrating. Carbamazepine:drowsiness,dizziness,stomachupset,visualsymptoms(egseeingdouble). Sodiumvalproate:nauseaandvomiting,sedation,diarrhoea/nausea. Rarebutimportantsideeffects Allthreedrugscancauseseriousdisorders.Arangeofbloodtestsisrequiredformonitoring. Lithium:blurredvision,shakingandtrembling,confusion,slurredspeech,nauseaandvomiting, diarrhoea,skinrashes.Advisethepatienttostoptakingthemedication,todrinkwaterandtoseethe doctorimmediately. Carbamazepine:leucopenia,aplasticanaemiaandagranulocytosis.Advisepatientstoreportany symptomsoffever,rash,sorethroat,infections,mouthulcers,easybruising,palenessofskin, weakness,bleedingorsmallpurplespotsontheskin. Sodiumvalproate:rash,impairedplateletfunction(patientbruiseswithoutreasonandbleedseasily), impairedliverfunction(thepatientfeelssleepy,issick,losesappetite,theskinmaylookyellow).Stop takingthemedicationandseethedoctorimmediately.

Important notes about mood stabilisers

Itisessentialthatthesedrugsaretakenregularly.Iflithiumisstoppedsuddenly,thereisaveryhigh

chancethattheillnesswillreturn.Ifthepatientmissesseveraldoses,theymayneedanewbloodtest tochecktheirbloodlevels.Ifcarbamazepineorsodiumvalporateisbeinggiventohelpcontrolfitsor blackouts,missingadosecancausethefitstoreturn. Ifthepatientdoesnotturnuptocollecttheirmedication,seekthemoutandaskhowtheyare.Ask thestafftoo.Itispossiblethatthepatienthasnotcometocollectthemedicationbecausehe/shehas becomemoredepressed,withincreasedlethargy,hopelessnessandanincreasedriskofsuicide. Ifapatientmissesadose,donotgivetwoormoredosesnexttime,asthismayincreasesideeffects.If apatientmissestwoormoredoses,referthemtoadoctorforbloodlevelchecks. Remindthepatientoftheimportanceofreportingandrespondingtoearlysymptomsoflithium toxicity.Makesurehe/shehasacopyoftheinformationsheetonlithiumtoxicity(itisonthe disk).Themostcommoncauseoflithiumtoxicityisdehydration,whichmayoccurduringhot weatherorphysicalexertion.Othercausesareurinarytractinfectionandillnessesthatcause vomitinganddiarrhoea.Thesemayoccurdespiteregularbloodtests. Remindpatientstakingcarbamazepineoftheimportanceofreportingimmediatelyanyfever,sore throat,infections,mouthulcers,easybruising,palenessofskin,weakness,bleedingorsmallpurple spotsontheskin. Remindpatientstakingsodiumvalproateoftheimportanceofreportingimmediatelyanyjaundice andabdominalpain. Drugs used for treating attention deficit hyperactivity disorder (ADHD) ThemostcommonlyuseddruginADHDismethylphenidate(Ritalin).Itisastimulantandshouldbe usedalongwitheducational,socialandpsychologicalhelp.Methylphenidatecanhelpayoungpersons

abilitiestoconcentrateandreduceoveractivityanddestructivebehaviour.Itisusuallyavailablefrom specialistcentresonly,andfromgeneralpractitionersundersharedcareagreementswithspecialist centres.Itisalsosometimesusedtohelpnarcolepsy(asleepdisorder),depressionintheelderlyandfor ADHDinadults.

Side-effects
Themainsideeffectsarenervousness,lackofsleep,lackofappetiteandstomachache.Thesecan sometimesbereducedbychangingthedoseorchangingthetimesofthedoses.Sometimesthedrugcan slowdowntherateofgrowth,althoughtheyoungpersonwillstillenduptheheighttheywouldhave done.Lessoften,sideeffectssuchasfeelingsickandskinrashescanoccur.

Important notes about medications for ADHD

Methylphenidateisastimulantdrug.Itcanbeaddictive,especiallyinadults.Takeespecialcarethat
thedruggoestoandistakenbythepersonforwhomitisprescribed. Asmethylphenidateisastimulant,itisbestnottogiveitafter4pmasitmayinterferewithsleep. Coping with common side-effects of medication Somesideeffectsoccurcommonlywithmorethanonetypeofdrug.Itisimportantforpatientstoknow thatalldrugshaveunwantedeffects,thatthesevaryfromindividualtoindividualanddependonthe typeofdruganddosebeinggiven.Sometimesthesideeffectsdisappearafterafewdaysorweeks, whileothersideeffectsaremoretroublesomeandpersistent.Itisveryimportantthatthepatient reportsanyunwantedeffectsthedrugseemstobehavingtohis/herdoctor.Theunpleasanteffectscan oftenbeeliminated,reducedinseverityormademoretolerablebyarangeofsimplestrategies.The strategiesthedoctormaysuggestincludethefollowing. Changingtoadifferentmedication. Decreasingthedose. Takingthedruginseveral,smallerdosesspreadthroughtheday. Takingthemedicationwithappropriatefood. Takingextramedicationtocounteractthesideeffects. Strategiesthatyoucanadvisetohelppatientsdealwithsideeffectsincludethefollowing: Sideeffect Appetite(increase) Strategyforcopingwithit Eatadietlowinfatandhighinfibre. Avoidsugaryorfattyfoods. Drinklowcaloriesoftdrinks. Increaseexercise. Increasefibreindiet. Increasefluidintake. Getupslowlyfromlyingorsitting. Avoidexcessivelyhotshowersorbaths. Avoidalcohol,sedativesorothersedatingdrugs(egmarijuana).

Constipation

Dizziness

Drowsiness Takemedicationinasingledosebeforebedtime(talktothedoctorabout thisfirst).Ifyoufeelsleepyduringtheday,youshouldnotdriveorworkwithmachinery. Drymouth decay). Ensurearegularfluidintake. Limitalcoholandcaffeine(bothenhancewaterloss). Usesugarlessgums,fruitpastillesandlollies(sugarwillpromotedental Suckonicecubes. Ifitisverybad,askyourdoctoraboutartificialsaliva(Luborant). Takemedicineafterfood.Consultwiththedoctor. Avoidthemiddaysun. Regularlyusesunscreenandwearahat,sunglassesandshirt. Askyourdoctorforaprescriptionforsunscreen.

Stomachupset Sensitivitytosunburn

Apatientinformationsheetisavailableonthedisk.

Administering medication: general issues Themainissueinadministeringmedicationinaprisonsettingishowtomakesurethattheright medicationgoesto,andistakenby,therightpatientattherighttime.Allpsychotropicmedicationsand manymedicinesusedforphysicalconditions(eganalgesics)alsomaybeusedascurrencyonthewing. Patientsmaysellorgivethemtootherprisonersorbepressured/bulliedintodoingso.Thereisalsothe possibilitythatpatientsmaysavemedicationandthenuseittooverdose. Otherissues,commontoadministeringpsychotropicmedicationinanysetting,includethefollowing: Howtoprovideinformationaboutthemedicationanditssideeffectstoallpatients,andalsothose withcommunicationdifficultieswhomaynotunderstandtheinstructions.Informationtendsto increasecompliance. Whattodoaboutthosepatientswhoarenotcapableofmanagingtheirownmedication,egthose withlearningdisability. Howtoencouragecomplianceorconcordancewithoutinfringingtherightsofpatientstorefuse medicationtheydonotwant.Thisisaparticularissuewithantipsychoticmedicationespeciallydepot injections.

Possible solutions
Amajorresponsetotheproblemofreducingtradingandthehoardingofmedicationistosupervise consumptionofmedicationgivingitonlyinsightandnotinpossession.Thissolutionmay, however,bringitsownproblems.Forexample,givingmedicationinsightratherthaninpossession may: meanthatthedoseisgivenatthewrongtime.Forexample,asedativecouldbegivenat4.00or5.00 pmandsobeineffectiveinhelpingtheindividualsleepatnight turnmedicationintoabattlegroundbetweenpatientsandhealthcarestaffand makeitdifficultorimpossibletogivemedicationtwiceorthreetimesperday. Thedecisionaboutwhetheranyparticularmedicationshouldbegiveninpossessionornotisan individualone.Itwilldependuponthetimingofthedose,thenumberofdosesneededperday,the patientsabilitytounderstandhis/hermedication,theriskofabuse,etc.Whethermedicationistobe giveninpossessionornotandthereasonsforthedecisionshouldbedocumentedinthenotes.

Systems and policies about medication

Effectiveprogrammesforadministeringmedicationincludethefollowing: Trackingandmonitoringsystemthatrecordswhetherpatientsareturningupforandtakingtheir medication.Activelyseekingoutthosepatientswhoareconsideredtobeatriskwithouttheir medication(includingthoseonantipsychotics,moodstabilisersandsomeonantidepressants)who donottakeit. Regularreviewsofmedication.Reviewswillideallytakeplaceinaclinic,bemultidisciplinary,and includetheprescribingdoctorandadministeringnurse/HCOwhotogetherreviewcompliance,the behaviourofthepatientwithregardtomedicationandthepatientsownreportofhis/herprogress. Regularlyscheduledpatienteducationalgroupsrelatedtotheuseofpsychoactivemedications.These areimportantandcanreducetheneedforinsightadministrationofmedications,withallits attendantproblems.Theyalsoincreasecompliance. Policyoninpossessionmedicationincludingflexibilitywithinthepolicy. Awarenessbyallwhoareinvolvedinadministeringmedicationoftheneedtoobtainpatientconsent andofwhattodoifapatientrefusestotakethemedication. Thepharmacistresponsiblefortheprisonwillbeavaluablesourceofadviceinsettingupsuch medicationsystems. Resources for patients and primary support groups MentalHealthDrugsHelpline:02079192999(MondayFriday,excludingBankHolidays,11am5 pm) (Thehelpline,runbytheUKPsychiatricPharmacyGroupandstaffedbyexperiencedmentalhealth pharmacists,providesindependentadviceandinformationaboutdrugstopatientsand professionals.TheChairoftheGroupalsorunstheDruginformationwebsiteformentalhealth serviceusers,whichcontainsdetailed,userfriendlyinformationonpsychiatricdrugs: URL:http://www.nmhc.co.uk)

PrisonServiceHealthPolicyUnit:02079722000 DepartmentofHealth,WellingtonHouse,133155WaterlooRoad,London SE18UG (PharmacyandpharmacyrelatedinformationrelatedtothePrisonService)