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OF mental health care and mentally ill

Key principles in medicines management

The following principles of practice are common to all areas of medicines management, irrespective of diagnosis or nature of pharmacological interventions.

Recovery

The concept of recovery in mental health has had many defi nitions. From a traditional medical perspective, recovery occurs when symptomatology is eliminated and the person returns to previous state of health and functioning, yet this clinical defi nition is now seen as inadequate to describe what recovery means to an individual. The effects of mental illness can impact on all aspects of a person’s life, and recent descriptions have incorporated this idea. The concept of recovery has taken a meaning which refl ects people’s ability to engage in a process where they re-take control and responsibility over their lives, developing hope and optimism for the future, learn to adapt and maximise their strengths, and rebuild and reclaim their self-confi dence and value in society . Service users have identifi ed the use of medication as a helpful strategy in moving towards recovery. A stated aim of medicines management is developing the person’s self-effi cacy in managing his/her pharmacological treatment. In this context, service users may decide on a variety of medication options. They may wish to titrate their medication against their subjective experience of illness/wellness. They may request work to develop a crisis medication plan against an assessment of their early warning signs. They may wish to try to become medication-free.

These are areas where the practitioner can help minimise the risks through planning and support. The theme of recovery will be revisited throughout this book to highlight the areas where medication and the role of the practitioner can enhance this process. Adherence and consent Non-adherence to medication has been cited as a major problem across all healthcare groups, especially when used for long-term chronic illness management, where about half the medication prescribed is not taken . Sufferers of schizophrenia are fi ve times more likely to experience a relapse if they decide to discontinue their medication (Robinson et al., 1999). Subsequent relapses lead to increased recovery times, poor long-term outcomes (Kane et al., 1998) and reduced levels of functioning (Hogarty et al., 1991), presenting a range of negative consequences for the person and his/her family. For some people non-adherence can also result in depression. This carries the risk of an accumulation of medication in the person’s home, providing a ready means of acting on suicidal ideas. The circumstances that result in non-adherence stem from two root causes. It can be unintentional, the result of forgetting or poor administration routines.

In these situations interventions can be put in place to attend to identifi ed diffi culties. Intentional, also called ‘covert’, nonadherence, is where the service user decides not to take all or a proportion of the prescription and, commonly, does not tell the care team about this decision. Another aspect of non-adherence is where a ‘supervising’ relative holds a negative appraisal of the medication and withholds or administers doses below that prescribed to the relative . There is an interface between the concepts of adherence and consent; they are both concerned with taking prescribed medication. Engaging the service user in the process of consent is a fundamental right. It is also an important aspect in developing the therapeutic relationship and enables people to feel in control of their health care and demonstrate their personal responsibility in directing treatment . This can be a diffi cult and sometimes controversial procedure, given the complexity of medication-related information that service users need to review in order to be considered ‘informed’, where cognitive diffi culties may hamper the successful learning of material or the person feels pressured to accept the treatment and the issue of capacity to make a valid decision. Medication is usually prescribed to a service user when the condition is in its acute phase.

In some situations medication may be prescribed and administered in the service users’ ‘best interest’ as their mental state renders them incapable of providing valid consent. However, at the earliest opportunity the process must begin and be viewed as a process rather than an event: an ongoing collaborative practice that guides and underpins treatment goals.

In circumstances where the process of consent has been valid, that the service user is informed, free to choose and has mental capacity, practitioners need to be aware of the inclination to provide further ‘persuasion’ if the service user decides not to follow medical advice . The practitioner needs to be cognisant when applying strategies to improve adherence that these strategies are not seen as pressure to conform to the prescribed regimen.

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