CASE STUDY 9: CHRONIC SCHIZOPHRENIA CASE STUDY: Simon

Learning objectives By the completion of the case study participants will be able to: Describe the benefits of a team based approach (including psychiatrists, GPs, mental health nurses, psychologists, social workers and occupational therapists and others) for managing patients with chronic schizophrenia Describe the local referral pathways and support options for managing patients with chronic schizophrenia. __________________________________________________________________________

Simon is a 21 year old male who was diagnosed with schizophrenia several years ago. He had his first psychotic episode at 17 during which he believed aliens were sucking out his blood. He was scheduled and commenced on olanzapine. He has experienced 5 more psychotic episodes including one depressive episode. After this episode, sodium valproate was added to his medication and the anti-psychotic changed to risperidone. Some of the psychotic episodes were related to the use of marijuana and/or speed. He has trouble remembering to take his medications and is currently managed by a private psychiatrist and credentialed mental health nurse (under the Mental Health Nurse Incentive Program). He continues to occasionally use speed and smokes over 30 cigarettes a day.

Currently, Simon is on a disability pension and lives in rented accommodation. He gets emotional and financial support from his family and has a few friends but generally finds it hard to relate to others. He has been employed twice but been asked to leave on both

occasions for being too slow and having too much sick leave. In the last 4 months, the mental health nurse has noticed Simons self-care worsening normally fastidious about his appearance, his clothes are now dirty and he rarely makes an effort to look nice. His avoidant behaviour towards the basic tasks of daily living is increasing and negative symptoms (avolition, apathy) more apparent. Any request from his parents to undertake a particular task leads to anxiety and the feeling that he cannot cope in response, Simon lays for hours watching television and smoking or goes to bed. He is no longer cooking meals but living on take-away and admitted to be very anxious that the landlord keeps harassing him regarding the lack of upkeep of the rental accommodation. He is increasingly having trouble managing his money and undertaking tasks that require higher level planning. Simons relationship with his family appears to be deteriorating as his requests for money become more frequent and increasingly abusive. The nurse also indicates concern about Simons continued weight gain - he has been steadily gaining weight and now weighs 136kgs.

Discussion points 1. As a team, develop a management plan for Simon. 2. How would you include Simons family in his management plan? What local services are available to support them? 3. Are there aspects of Simons psychosocial functioning that might benefit from input from other mental health professionals? Which of the following programs listed in Table 1 could be used to access these services? Answer the questions specific to the program you choose to refer Simon.

Table 1: A sample of relevant Mental Health Care Programs available to practitioners

 Better Access (BA)

What steps are needed to make the referral?

Personal Helpers & Mentors Program

What steps are needed to make the referral?

Which health professional would be most appropriate to refer to? How would you access the required health professional?

How would you access the service?

What information would be useful to include in the referral?

What information would be useful to include in the referral?

What type of psychological intervention would be appropriate to request?

In what ways could this program support Simon?

What are the requirements with regard to patient consent in relation to treatment and sharing information among health professionals?

What are the requirements with regard to patient consent in relation to sharing information among health professionals?

What information does Simon require about his referral under this program?

What information does Simon require about his referral under this program?

What type of information should be provided back to the referring health professional?

What type of information should be provided back to the referring health professional from the helper/mentor?

4. What other health professionals or services could be helpful in including in Simons care? 5. How could you facilitate case conferencing between the team involved in Simons care?

Notes for facilitator: The identity of the person in the case study and the locality can be changed to suit the particular demographics in your area e.g., the setting could be stated as a small rural community or the patient could be identified as belonging to a particular cultural or linguistic group. Listed below are some key points that facilitators might find helpful to include when working through the discussion questions with their network group. Facilitators may use these points as suitable prompts to develop a richer discussion of the issues.

Important issues to be covered in group discussions: Question 1: Issues that need to be addressed include: poor adherence to medication, weight gain (Is this medication and/or diet and exercise related?), increase in negative symptoms, poor coping skills (coping by withdrawal, cigarettes), anxiety, loneliness, family stress, unemployment, potential for loss of accommodation, high potential for relapse, welfare of family members Establishing if Simon has a regular GP would be fruitful. The GP could assist with the monitoring of blood glucose levels and address general health care. Ensure the group is clear about who is coordinating the case in this case, it is the psychiatrist.

Question 2: What local carers support groups are available? How could you find out this information? Members of Simons family may be experiencing anxiety or depression in response to the stress of the situation. They may require support from the psychiatrist or a referral for psychological intervention.

Question 3 / 4: There is increasing evidence of the utility of cognitive behavioural interventions with schizophrenia. Psychological therapy could fruitfully target Simons difficulty managing stress especially his choice of coping skills, physiological arousal and cognitive processes. Useful components of psychological therapy might include: daily activity schedules, behavioural assignments to increase activity levels and pleasurable activities, relaxation skills, cognitive work with distorted or negative beliefs especially related to self and social situations, social skills training. An issue in providing interventions is the importance of developing a therapeutic alliance with Simon. It would be useful for the group to discuss how this could be achieved. A possible disadvantage of obtaining psychological therapy through the Better Access program is the time limited nature of the sessions. Developing a therapeutic alliance with Simon may take some time and there is potential for harm if the relationship has to be ended prematurely. Psychological therapy might be appropriate if it clearly targets a specific aspect of Simons care. In addition to providing specific mental health care under Better Access, a social worker could be of assistance to Simon in terms of the social consequences of his illness and his welfare needs. In addition to providing specific mental health care under Better Access, an occupational therapist could fruitfully address Simons functional abilities and thus assist rehabilitation. The Personal Helpers and Mentors program offers potential for Simon to get day to day assistance in managing his life. The group needs to explore local availability of this service. Another option is the Housing and Accommodation Support Initiative (HASI). Many non-government organisations provide activities and groups that could provide Simon with social support.

Question 5: Case conferencing is often difficult to arrange due to the high workloads of most health professionals, lack of administrative support, and the lack of funding available for private allied mental health professionals to engage in case conferencing. Arrangements for case

conferencing are thus best arranged at the local level in a manner that best meets the needs of the local professionals this is an ideal opportunity to develop local systems. Case conferencing will be facilitated by having a clearly identified case coordinator. MBS items to organise a case conference are available for psychiatrists, consultant physicians (e.g., paediatrician) and GPs. Item numbers are also available for paediatricians, psychiatrists and GPs to participate in a case conference. Some information on case conferencing is available in the resources section of this Manual and full details on the relevant item numbers can be found in the Medical Benefits Schedule available online at: http://www.health.gov.au/internet/mbsonline/publishing.nsf/Content/Medicare-BenefitsSchedule-MBS-1