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MEDICATION MANAGEMENT
Treatment usually begins with the initiation of antipsychotic medication. For those clients who initially refuse drug management, the case manager continues to provide support and education to the patient and family. The choice of antipsychotic medication is established through a treatment protocol (see Figure 3) which is explained to the client and family by the psychiatrist.
Antipsychotic therapy is the cornerstone of treatment of psychosis. While necessary, antipsychotic drugs are not sufficient in themselves to treat psychosis and must be integrated with other (psychosocial) treatments (See Psychosocial Interventions).
All antipsychotic drugs are more or less equally efficacious. However, special considerations are necessary when treating individuals with a first episode of psychosis, most of whom are young, and have never been exposed to these powerful agents. In order to avoid immediate discomfort associated with motor side effects and dysphoria associated with typical antipsychotic drugs, low doses of novel antipsychotic drugs are advised to be the first choice. In PEPP, patients are started on as low as 0.5 mg to 1 mg of Risperidone (or equivalent doses of other novel antipsychotics) and gradually increased to 2 mg a day over several days depending on patient's clinical condition and ability to tolerate the drug without any discomfort (such as akathesia). Novel antipsychotic drugs are used according to the protocol alogorythm attached (see Figure 3). Initial treatment is started with one of the novel antipsychotic drugs (usually risperidone or olanzapine). Side effects are monitored closely for both in and outpatients by all clinical staff involved (in particular their case managers).
Standardized assessments for rating of symptoms and side effects are conducted according to a set protocol at regular intervals (see assessment protocol).
If the patient is started on an antipsychotic medication on an outpatient basis and if this is the very first dose of an antipsychotic, the case manager keeps in close contact with the client. The case manager will then follow-up with a visit and telephone calls for the next few days. In the early stages of treatment, the majority of the case manager's time is spent helping the client and family adjust to the issues around antipsychotic medication including symptom relief, side effects, compliance, etc. After initiating antipsychotic therapy a patient is assessed by the psychiatrist in collaboration with the case manager weekly for the first two to four weeks and then biweekly for the first two months. The frequency of assessment by the psychiatrist is then reduced to once a month if clinically feasible. Although there is a recommended schedule for review of medications, the psychiatrist will see the patient as often as is seen clinically desirable.
The case manager's attitude and knowledge of the medication is of great importance for a number of reasons. Firstly, families and clients have unlimited access to the case manager and s/he, therefore, is their primary contact for obtaining the help and information they need. Secondly, the case manager plays an instrumental role in monitoring and occasionally administering the medications throughout the follow-up period. Enquiries about side effects are made on a regular basis. Thirdly, families and clients often feel more comfortable articulating their concerns and questions to the clinician with whom they have become familiar as a result of the close and frequent contact. The case manager plays a key role in communicating the client and family concerns regarding the efficacy and side effects of the medication to the psychiatrist.
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