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Quality of life (QOL) in schizophrenia is increasingly being recognized as an important patient-related outcome measure both in routine clinical.
Table of contents
- Beyond Assessment of Quality of Life in Schizophrenia | A. George Awad | Springer
- Unmet needs in the management of schizophrenia
One of the most common risks of a person suffering from schizophrenia under community care is being admitted to a hospital because of his or her mental conditions. The mere fact of hospitalization is a risk in itself because of the added stigma, plus the frequent suffering of lowering self-esteem and loss of dignity perception when coerced into involuntary treatment. Moreover, mostly if admitted compulsory, patients may also suffer other means of coercion to restrain their movements, such as mechanical constraint, isolation, or administration of nontherapeutic aimed drugs.
We could add that when some users were asked in focus groups not published , none of the coercive measures were naive to the patients, and in some cases patients felt them as an attack on their dignity. This statement certainly needs more research, using an appropriate qualitative method if possible. Quite a few of the most recent documents of the international bodies and multinational agencies support this and offer similar recommendations toward the same aim. For a long time it has been known that there are patients who show unmet needs of service contact or unmet needs of psychosocial contact and of pharmacological treatment.
Lack of insight, past experiences, and prejudices against health services, among other reasons, make this group of people reluctant to maintain therapeutic links.
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They live in the community, and without adequate treatment, they are at risk of progressive health deterioration, forced reinstitutionalization, or even imprisonment. The first of the two previously mentioned World Health Organization reports 6 proposed ten recommendations to address the TG:. More recently, a systematic World Psychiatric Association survey of leaders of psychiatry was completed in almost 60 countries, examining strategies to reduce the TG.
Case management, intensive case management, assertive community treatment, and assertive outreach are or have been the most common names used to refer to successive models of community care specifically oriented to satisfy the unmet needs of the SMD. It has been long known that assertive outreach and intensive case management can reduce hospitalizations of patients who are frequent users of inpatient care and can reduce overall mental health care costs.
In addition, greater fidelity to the models produced better outcomes. SMD is very frequently found in the excluded homeless population, making it more difficult to engage them in services care. It is then that assertive community treatment offers significant advantages in reducing homelessness and symptom severity in homeless people with SMD. These models of intensive care outreach services can have significant benefits in terms of patient outcomes and service use.
Moreover, the implications of specific nursing programs provide a useful framework for evaluating the effect of these services. A recent Cochrane review found that intensive models of community care were more effective for several relevant outcomes of people with SMD. These not only reduced hospitalization and increased adherence to care but also improved social functioning, although the effect on psychopathology was not so clear.
The effectiveness comparison of numerous attempts of available community models would be beyond the scope of the present revision. Very recently, a Cochrane Systematic Review considered a new movement aimed at increasing the adherence of those patients with SMD who are reluctant to seek care.
Beyond Assessment of Quality of Life in Schizophrenia | A. George Awad | Springer
The review compared past or present users of mental health centers that were providing care versus professionals enrolled in case management. There were no significant differences between the two groups in clinical psychopathology, satisfaction, adherence to care, or withdrawing from the study, among other variables. Those receiving care from past or present users of mental health services used crisis and emergency services slightly less frequently than those receiving care from professional staff. Regarding care procedure, it was found that past or present users spent more face-to-face time with patients.
The author invites others to further research this matter, reinforcing the methodological approach and changing the location in diverse settings, including low- and middle-income countries. Vast research efforts will be needed to find appropriate ways to meet them, particularly regarding the so-called existential needs, but many could be met only by applying existing evidence-based interventions. Despite the general awareness of protocols, algorithms, and clinical practice guidelines, research findings are slow to reach into the daily management of schizophrenia, and many useful and cost-effective techniques are ignored in practice.
Regarding unmet health needs, evidence-based organizational techniques for the management of chronic disorders could be applied extensively to severe mental disorders. This model of care rests on the performance of a case manager responsible for monitoring patient progress, providing assertive follow-up, teaching self-help strategies, and facilitating communication between the patient, the family doctor, the mental health specialist, and other specialists.
Unmet needs in the management of schizophrenia
There are also unmet needs brought about by the psychiatric interventions themselves. Antipsychotic medications, while improving positive symptoms, may cause a variety of adverse effects that seriously interfere with quality of life. Use of low dosages, and even discontinuation of these medications in judiciously selected cases, will help to alleviate this problem as well as improve long-term functioning. Serious damage to quality of life may also come from some psychosocial interventions. The use of coercive procedures such as compulsory admission, community orders, or simple leverage, whether clinically justified or not, can be extremely detrimental to the quality of life.
The participation of users and relatives in the planning and evaluation of mental health services and the growing collaboration between users, families, and mental health workers are key factors in bringing about the necessary change in these attitudes and behaviors. The incorporation of users in providing formal care within statutory mental health services is another example of this collaboration. One major advance in approaching the management of schizophrenia comes from conceiving it as a neurodevelopmental disorder that progresses in identifiable stages. Each developmental stage, modulated by sex and the phases of the vital cycle, is associated with different medical and psychosocial needs, and hence requires different and specific interventions.
Another issue concerns social policy and the availability of community facilities to cover basic social needs.
Quality of life is associated with employment, income, and housing stability. Unemployment, poverty, and housing instability are high among people with mental health problems, and even more so in times of economic recession.
Along these lines, the preservation of the welfare state is critical. During the last decade, coinciding with the economic crisis and as a consequence of a tide of privatizations driven by neoliberal ideologies, some public health services in Europe are being dismantled.
Advocacy for protecting the basic rights of persons with SMD is now more necessary than ever. Outcome measures and needs assessment tools for schizophrenia and related disorders. Cochrane Database Syst Rev. The Camberwell Assessment of Need: the validity and reliability of an instrument to assess the needs of people with severe mental illness. Br J Psychiatry. Int J Soc Psychiatry.
Epub April 10, Standardised measures of needs, stigma and informal care in schizophrenia using a bottom-up, cross-cultural approach. Ment Health Fam Med.
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