General Principles

Kulkarni [72] has outlined the following features of home-based care required in early psychosis.

The Individual and the Illness

Severe psychotic illness in itself is not a barrier to successful home-based treatment. Clinical experience suggests it is the dangerousness of the symptoms, rather than their intensity, that determines whether patients will require hospitalization. Suicidal and homicidal thoughts, as well as hostility directed towards family members that is driven by delusions, will encourage hospital admission rather than home-based care. Access to firearms and other weapons needs to be assessed.

Illicit substance abuse, particularly of cannabis and amphetamines, can precipitate and perpetuate psychosis. The family needs to be able to prevent access to illicit drugs during the acute phase of the illness.

The role of the patient in the family and compliance with treatment need to be evaluated. A shared illness model involving patients, their families and clinicians can be useful but is not always necessary for success. It is more useful to reach agreement on management strategies and their implementation rather than the possible reasons for the onset of psychosis.

The Family

The needs and capabilities of the family must be carefully assessed, as they will be the primary caregivers. Families of hospitalized patients are usually of secondary importance in mental health care systems, but in home-based care their welfare and health are more important. Work schedules, the availability of family members and their resources in terms of extended family or friends are important issues.

Poor family interactions and pre-existing family problems may be exacerbated during this time of disruption and stress. However, high expressed emotion can be of value - provided the hostility and critical components are not pronounced - as people with families that might otherwise be considered "over-involved" tend to remain engaged in treatment and recover more quickly than people with distant, disengaged families.

Containment is an important ingredient of treatment in acute psychosis. The family must be empowered to enforce containment, for example by confiscating car keys. There is a need to avoid "splitting" the family on the best course of action for containment.

Implementation and explanation of clear management plans to the family is very important, particularly as early family reactions to a psychotic illness can involve confusion, guilt, denial and emotional numbing. They must receive an unambiguous message about the likelihood of a favourable outcome and recovery from the acute phase.

Table 2.14 is a checklist for the initiation of home-based treatment, from the family perspective.

Table 2.14 Checklist for the initiation of home-based treatment.

• Family member requires treatment.

• Family member is not able to attend appointments at community-based services.

• Clinician's and family's risk assessment indicates that home-based treatment is a safe option.

• The collective resources of the treating team and the family enables provision of the required treatment.

• Family understands the tasks involved in home-based treatment.

• Family is willing to take on home-based treatment.

• Good communication can be facilitated through qualified interpreters when needed.

Treating Team

A team treating a patient at home is working in a very different environment from that in a hospital or clinic. They are ''guests'' in the patient's home, and need to respect power relationships within the family. Challenges they must face include:

• a loss of control over the working environment;

• a lack of access to medical equipment;

• diminished access to colleagues;

The work requires great flexibility, and staff treating acutely ill patients at home need to be experienced and confident as they make decisions about the safety of the patient and family, and monitor diverse aspects of treatment.

Staffing numbers in a home-based treatment service need to be high enough to allow up to three visits each day. There is a risk of staff ''burn-out'' from the high demands, so integrating home care into larger systems may help to spread the load and provide greater flexibility. A larger team which provides both home-based intervention and continuing care can ensure continuity of care, with follow-up from the same clinicians. The risk of this approach is that the focus and priority for home-based care can get lost.

Confidentiality issues may arise when the family are functioning as primary carers, and it may be difficult to provide sufficient privacy for therapeutic interventions. Families will have little interaction with others in the same situation, and will depend on the treating team for information and education. The treating team must ensure that all aspects of management are covered. There are usually well-established protocols for assessment and treatment in hospital and clinic settings, but they may be undermined by the flexibility essential in providing home-based care.

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