Specific Strategies

Treatment Package

All participants in home-based treatment need a structured management plan. A ''treatment package'' can be used to provide a written timetable which outlines step-by-step treatment plans. In addition, it will reinforce expectations about the course of the acute episode of psychosis and the likelihood of recovery. Treatment packages should be formulated individually with the patient and carers, avoid jargon, and be based on pragmatism and optimism. The plan also provides a reminder of standard protocols to the treating team. An example is shown in Table 2.15.

Plans for the recovery phase and further follow-up can be developed at the same time, reinforcing signals to patients and their families about the expected progress.

Medication Management

Sedation of the patient is usually needed in the hyperacute phase of psychosis to quickly reduce anxiety. This is especially important to allow an

Table 2.15 Home based care: crisis and acute phase (adapted from 72)

Initial phase - commonly 2-7 days

• Formulation and delivery of the individual "package" of care.

• Provision of a clear visiting schedule by the treatment team.

• Medication (usually sedative, e.g. temazepam), then choice of an appropriate atypical antipsychotic.

• Organize blood tests, X-rays etc., to check physical health.

• Assessment of troubling symptoms.

• Discussion with family on helping them to cope and gathering information about the patient prior to the illness.

• Get to know the patient and family, and allow them to get to know the treating team.

• Liaison with patient's general practitioner.

Acute phase - commonly 7-10 days

• Monitor type and dose of antipsychotic medication.

• Treating team to initially administer medication, then hand over to family with clear verbal and written instructions.

• Team to monitor pulse, blood pressure and response to medication.

• Discuss with patient and family the nature of psychosis and how medications work.

• Deal with issues of leave from work and organize certificates.

anxious and vigilant family to rest and "re-group". Sedating benzodiazepines such as temazepam are useful in this phase and can be used during the day if necessary, as well as at night.

Decisions about the choice of antipsychotic medication in these circumstances are very important. It is essential to prevent any dangerous side effects as constant clinical monitoring is not available. The treating team should carry emergency kits of anticholinergic medication with intravenous and intramuscular injection equipment, as well as other emergency medications and resuscitation equipment. Antipsychotics which possess a "gentle" onset of action and yield fewer side effects are preferable to drugs which carry a high risk of extrapyramidal side effects. This essentially means atypical antipsychotics. As with all first-episode patients, the initial doses of antipsychotics should be low and increased slowly, relying on benzodia-zepines in the short term to assist with rapid symptomatic relief.

Physical Investigations

Physical investigations which are part of the routine assessment of patients with first-episode psychosis may be more difficult to organize in home-based treatment, but should not be overlooked. Some pathology services collect samples at home, and specialized tests such as CT and MRI can usually be organized on an outpatient basis.

Psychosocial Issues

Stressors and the patient's method of coping with them need to be addressed early in a first episode of psychosis. These can include psychosocial stressors, abuse of substances in response to stress, and sleep deprivation, which worsens emerging psychotic symptoms.

Ideally, home-based treatment will lead to more rapid reintegration into the community, with much less of the secondary morbidity often associated with hospitalization. However, patients who have been treated mainly at home may be unwilling to participate in formal recovery programmes and are more likely to use denial as a recovery style. General community-based programmes for specific skills training or other socialization needs may be more appropriate than "psychiatric" day programmes.

Need for Hospitalization

If hospitalization becomes necessary during a period of home treatment, it should not be viewed as a "failure". The treatment team has the opportunity to facilitate a non-traumatic hospital admission, and then provide follow-up after discharge.

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