Focus on Mental Health

Collaboration: The Newest Technology...

The upcoming 2007 Rehabilitation and Transition Conference will focus on mental health. From a psychiatric perspective, these are some of the more important developments within the mental health profession over the last year that will have direct relevance to rehabilitation work.

First, three important, non-industry sponsored studies of psychiatric medication have been completed – CATIE, STAR*D, and STEP-BD – looking at schizophrenia, depression, and bipolar disorder respectively. These studies are large, multi-site, effectiveness studies (long-term in the real world) and were independently funded, meaning the quality of the information gained is exceptional. The results are surprising and sobering. Clients on antipsychotic medications change medication more often than not, either for reasons of lack of efficacy or problems with side effects. It appears that the older antipsychotics are just as effective as the newer ones, but the difficulty with side effects persists and is significant. The more effective the drug is, the more problems it creates for the client.

From the STAR*D study, it is clear that depression is a difficult illness to treat. Our goal is complete remission of symptoms, since partial remission leads to relapse and poor quality of life. Overall, the best that can be done with excellent care and multiple drug trials appears to be only 60% success.

As far as STEP-BD, it was learned that even when clients are able to achieve remission from their bipolar episode and are medication compliant, they are very likely to relapse in 2 years, usually into a depressive episode.

These studies demonstrate several important facts about mental illness:

1. Mental illnesses are relapsing conditions, often with a chronic presentation.
2. Treatment with medication may be an important part of medical care, but it is far from enough.
3. Our mental health clients need quality, ongoing psychosocial treatments in addition to medication.

As our hopes for Super-Prozac and Super-Clozaril have dimmed, there has been a corresponding increase in interest in cognitive-behavioral therapy. CBT allows the client and caregiver to work collaboratively in defining and managing many different mental health issues – negative thoughts, depressive behaviors, sleep problems, bipolar relapse, panic attacks, even psychotic symptoms. The care does not need to be delivered by an MD or PhD, does not need to involve medication, and the effects seem to be quite long-lived after the therapy ends.

CBT is also in harmony with the recovery model for the delivery of mental health care. Nearly all of the community mental health systems in Wisconsin have adapted aspects of recovery as part of their programs. Recovery incorporates many principles from rehabilitation and transitional care, as well as from substance abuse treatment. The fundamental idea is that when dealing with disabilities that are long-term, an acute care medical model is not appropriate, or helpful. Instead, what is needed is an emphasis on collaboration, motivation, resiliency, and individualized care that empowers clients and families.

So as we move into 2007, there is increased recognition that the medical model of acute care, delivered in an outpatient clinic or emergency room, is not going to be sufficient to relieve the suffering and disability of people struggling with mental illness. What is called for is a partnership among many different professions, as well as with clients, all working together to bring treatment and support to those who need it.

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