Medication compliance

Differing terms are used for compliance, including concordance and adherence. This chapter examines the range of obstacles to compliance, including side effects, lack of insight, lack of effectiveness, and resistance to being reminded of the illness. The influence of family and friends is also considered. We believe it is often best to avoid complex explanations, and just accept that it is difficult to remember to take medicines regularly for months and years. Several strategies exist to improve compliance, including depot preparations, psycho-education, and efforts to strengthen the therapeutic relationship. Compliance therapy, based on motivational interviewing, is described in detail. The outreach worker is also uniquely able to rely on prompting and support as well as careful monitoring and structuring the clinical interview to ensure that compliance is regularly assessed. Supporting compliance is a long-term commitment, not a once-off intervention.

Violence and Psychosis; Treating the Untreatable (Novel Pharmacological Approaches)

Often the final pathway for psychosis is the forensic services. in many other cases the only options are prison or no care at all. Despite much research into the psychopharmacological approach many patients are either unresponsive or unable or unwilling to take medication. Many clinicians would support the early use of clozapine for these patients but despite the availability of clozapine in Europe for nearly 20 years the numbers who are treatment resistant are still highly significant. This affects patients, carers and indeed potential victims and staff who are increasingly vulnerable. the eclipse of the typical anti-psychotics and the fear of extra-pyramidal side effects has led to many patients being prescribed oral atypical agents which they do not actually take. the result of, in many cases years, of untreated or part treated psychosis is severe cognitive damage. This then contributes to difficulty in managing the patient and lack of engagement in the therapy process. the emergence of new depot preparations may be the answer but the degree of D2 blockade may still not be sufficient and the addition of 5HT blockade may be also useful. in the forensic settings there is much made of risk assessment but the most efficient predictor of future risk is a stable patient on an effective treatment regime. Several options are described including double depot, high dose olanzapine and clozapine enhancement.

Treating of Schizophrenia in Malta

Malta is a small country in the middle of the Mediterranean. It is a member of the European Union and has a population of around 400,000. The culture is European, and around 99% of the population is Roman Catholic. There are no studies on the prevalence of schizophrenia in the Maltese population, but it is most likely that it is about 1%. During the last few years, thousands of illegal immigrants from Africa have been arriving in Malta especially during summer. It seems that the prevalence of schizophrenia in this subgroup is more than that in the local population. Studies are needed to study this phenomenon further to see if this is the case, but they are definitely being a big burden on the local psychiatric services. The National Health Service in Malta provides all treatment for schizophrenia free of charge. The pharmacological management of schizophrenia is similar to that of other European countries. Oral atypical antipsychotics are available within the National Health Services, but depot preparations are not yet available. For admissions there is a main Psychiatric Hospital, Mount Carmel Hospital, and two units in two General Hospitals. Community services are in the process of being developed. An NGO association, the Richmond Foundation also provides community and rehabilitation services. The Maltese family is still a relatively strong unit, with a lot of support in times of help being provided by the extended family. Thus in most psychosocial interventions, the family plays a central role.

Violence and Psychosis; Treating the Untreatable (Novel Pharmacological Approaches)

Often the final pathway for psychosis is the forensic services. In many other cases the only options are prison or no care at all. Despite much research into the psychopharmacological approach many patients are either unresponsive or unable or unwilling to take medication. Many clinicians would support the early use of clozapine for these patients but despite the availability of clozapine in Europe for nearly 20 years the numbers who are treatment resistant are still highly significant. This affects patients, carers and indeed potential victims and staff who are increasingly vulnerable. The eclipse of the typical anti-psychotics and the fear of extra-pyramidal side effects has led to many patients being prescribed oral atypical agents which they do not actually take. The result of, in many cases years, of untreated or part treated psychosis is severe cognitive damage. This then contributes to difficulty in managing the patient and lack of engagement in the therapy process. The emergence of new depot preparations may be the answer but the degree of D2 blockade may still not be sufficient and the addition of 5HT blockade may be also useful. In the forensic settings there is much made of risk assessment but the most efficient predictor of future risk is a stable patient on an effective treatment regime. Several options are described including double depot, high dose olanzapine and clozapine enhancement.

How can clinicians help patients to take their psychotropic medication?

Enhancing a patient's adherence to psychotropic medication regimens is one of the challenges facing all mental health professionals. Medication is part of an overall care package that often depends on patients' engagement with the clinician or service. The therapeutic alliance might be improved by more active listening to patients. A reduced capacity may limit a patient's ability to make a treatment choice. This can be improved by provision of more time and information. If these techniques are insufficient, closer monitoring may be achieved by working with relatives and carers, or more frequent visiting. Strategies to avoid covert non-adherence could include checking for picked up prescriptions and the use of depot preparations. Finally, the use of compulsory powers may be appropriate, with attention to preserving or rebuilding the therapeutic alliance.