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Recovery and Individuals with Serious Mental Illness: A Welsh Perspective
In the first of a two part series, this week I am looking at how a contemporary recovery model can apply to serious mental illness, within a Welsh service context. Next week I will consider in more detail how serious mental illness impacts the determinants of well-being, as outlined in the Social Services and Well-being (Wales) Act, 2014. In order to focus upon some specifics, I am considering treatment resistant schizophrenia as an example of serious mental illness.
Since William Anthony's seminal 1993 paper on recovery in mental illness, services have been challenged to balance a more traditional and medical conceptualisation of care and treatment against a far more person-centred and socially contextualised model of support. This type of support is heavily championed in The Social Services and Well-being (Wales) Act, 2014, and also fits well with the “Welsh Mental Health Measure of 2011.
I would like to consider what this means in relation to individuals with treatment resistant schizophrenia. These individuals are more likely to respond poorly to first line anti-psychotic medications and/or cognitive interventions to address delusional thinking, even if these are available. As a result they are likely to experience poor outcomes in relation to psychotic symptom control, experience higher level of comorbidity in the form of depression and anxiety based conditions, and be more adversely affected by social exclusion.
With regards to effects of illness and treatment options for these individuals:
- Clozapine remains the first-line medication for treatment-resistant psychotic symptoms. Clozapine has potentially serious side effects and needs to be monitored carefully via regular blood tests. Concordance with the regime is essential, but is paradoxically often difficult to achieve with individuals.
- Polypharmacy including use of second generation antipsychotics such as sulpiride, amisulpride, aripiprazole, ziprasidone and risperidone, and/or antidepressants or mood stabilisers is often seen in practice. Such regimens are complex and may further limit cognitive and physical functioning.
- Treatment-resistant negative symptoms (lack of motivation, loss of volition, fatigue) and simultaneous major depressive episodes are treated with antidepressants (SSRIs, SSNRIs or mirtazapine), while mood stabilizers and lithium may also be prescribed.
- Cognitive dysfunctions in the form of memory impairment, attention deficit, loss of acuity and compromised sensorimotor/coordination are common.
- These factors combined often result in social difficulties including difficulties adhering to social expectations re: appearance and behaviour, relationship breakdown, social isolation, and inability to work or study.
The 2014 Act conceptualises well-being not just as an absence of symptoms but, as Martin Seligman notes, as a "combination of feeling good...having meaning, good relationships and accomplishment." Furthermore, the recovery notion is consistent with the values of the Act in promoting empowerment, control and choice. These ingredients are essential if recovery is to be personal, meaningful and enduring.
But in the case of schizophrenia (especially where it is resistant to treatment and becomes an episodic and relapsing condition), the effects of illness, as outlined above, convey the scale of the recovery challenge. All the domains of well-being as espoused in the Act are likely to be negatively impacted - which is where I will pick up the story in my next article.
For the William Anthony paper see: https://cpr.bu.edu/wp-content/uploads/2011/11/anthony1993c.pdf