0

BACHELOR OF MEDICAL AND HEALTH SCIENCES

WITH HONOURS (BMHS)

<SEPTEMBER 2021>

< NBMH 3913>

<MENTAL HEALTH CARE>

NO. MATRIKULASI : 870517295649001

NO. KAD PENGNEALAN : 870517295649
NO. TELEFON : 016-6262687
E-MEL : rihaizan11@oum.edu.my
PUSAT PEMBELAJARAN : PETALING JAYA LEARNING CENTRE
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Table of Contents
Introduction...........................................................................................................................................2
2.0 Cuurent status of mental health......................................................................................................3
2.1 Epidemiological incidence of schizo.............................................................................................3

2.2 Risk factor....................................................................................................................................3

3.0 Management of schizo....................................................................................................................5

3.1 Acute Phase Mx...........................................................................................................................5

3.2 Relapse Prevention......................................................................................................................5

3.3 Stable phase................................................................................................................................6

4.0 Psychosocial Intervention................................................................................................................6

4.1 Family intervention......................................................................................................................6

4.2 Psychoeducation..........................................................................................................................6

4.5 Cognitive behavior therapy..........................................................................................................8

4.6 Counseling and supportive psychotheraphy................................................................................8

4.7 Multimodal intervention..............................................................................................................8

4.8 treatment adherent.....................................................................................................................9

5.0 Service level Intervention................................................................................................................9

5.1 Community mental health team..................................................................................................9

5.2 Assertive community support......................................................................................................9

5.3 Day Hospital Care......................................................................................................................10

5.4 Supported employment.............................................................................................................10

5.6 intensive case management......................................................................................................10

6.0 Conclusion.....................................................................................................................................11
7.0 References.....................................................................................................................................12
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Introduction
Schizophrenia is a severe mental illness that affects a person's ability to think, feel,
act, and interact with others. The sickness affects both men and women, but men are
significantly more likely to develop it. Men are more likely than women to have their first
episode in their late teens to early twenties. The sickness might also strike people later in life.

Homeless persons have a higher prevalence of psychiatric disorders, such as

schizophrenia and other psychotic diseases, than the general population (Ayano et al., 2019).
Mental problems are associated to a higher risk of disability and mortality from suicide,
general medical, and alcohol and drug-related causes among homeless people.

Aggressive behaviour is more common in schizophrenia patients than in the general

population. In one study, individuals were labelled aggressive if they used physical force or
displayed hostile or spiritually harmful attitudes or behaviours, such as verbal or physical
violence, self-aggression, or hostility toward others. According to new studies, schizophrenia
is a risk factor for violence (Saha et al., 2005). Aggressive behaviour is four to six times more
common in schizophrenia patients than in the general population.

Recovery from schizophrenia is a long and winding road that is unique to each
individual. Over time, the symptoms normally improve and become easier to manage, while
they do not always go away. The qualities of hope, empowerment, and optimism are
promoted in a recovery-oriented approach to schizophrenia treatment. A mix of drugs and
psychological supports, such as psychotherapy, education, and peer support, can usually be
used to effectively manage the illness. Schizophrenia patients can and do recover, leading
important and fulfilling lives.
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2.0 Curent Status Of Mental Health

2.1 Epidemiological incidence of schizophrenia
Schizophrenia affects about 26 million people globally today. Due to an interplay of
biological, genetic, and environmental factors, schizophrenia is a lifelong disorder with acute
exacerbations and varied degrees of functional dysfunction. As a result, patients with
schizophrenia may require a combination of treatments, such as psychopharmacotherapy,
psychosocial interventions, physical health care, and comorbidity treatment (Wu et al., 2018).

In Malaysia, a study of Years Lived with Disability (YLD) and nonfatal burden found
that mental diseases constituted 21% of the burden in both men and women. Currently, there
are 680 health centres that provide steady follow-up, early identification, and treatment, as
well as 27 health centres that offer psychosocial rehabilitation (Brown & Lau, 2016).

2.2 Risk factor

Many risk factors, both environmental and genetic, have a role in the pathophysiology
of schizophrenia. The date of birth, place of birth, and seasonal influences are all
environmental factors, as are infectious diseases, problems during pregnancy and delivery,
substance addiction, and stress. Genetic factors, in addition to environmental variables, are
thought to have a role in the development of schizophrenia at this period. Schizophrenia is
heritable in up to 80% of cases. If one parent has the disease, there is a 13 percent chance that
it will be passed down to the children. If both parents have it, the risk increases to more than
20%. Knowing these variables can help you avoid developing the illness (Cooke, 2014).

2.3 Diagnosis of schizophrenia

Operational criteria, such as those described in the DSM or International Statistical

Classification of Diseases and Related Health Problems, are used to diagnose schizophrenia
(ICD) (Saraceno, 1998). These criteria consider the typical positive, negative, and cognitive
symptoms of schizophrenia, as well as the length of those symptoms, their impact on social
and occupational functioning, and the probable involvement of other mental diseases, mood
disorders, and drug misuse concerns.

In clinical practise, diagnosis and categorization are still crucial challenges, and
acquiring a diagnosis of schizophrenia has significant social and emotional ramifications for
the individual. The DSM IV-TR and ICD-10 are used to make the diagnosis (Keks et al.,
2008).
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(Keks et al., 2008)

(Keks et al., 2008)

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3.0 Management Of Schizophrenia

3.1 Acute Phase Mx
The goals of treatment during the acute phase of treatment, which is defined by an
acute psychotic episode, are to prevent harm, control disturbed behaviour, reduce the severity
of psychosis and associated symptoms (e.g., agitation, aggression, negative symptoms,
affective symptoms), determine and address the factors that led to the occurrence of the acute
episode, effect a rapid return to the best level of functioning, develop an alliance with the
patient and family, and formulate a treatment plan with the patient and family (Yoon & Aziz,
2014). Attempts to engage and work with family members and other natural caregivers are
typically beneficial during the crisis of an acute psychotic episode, whether it is the first
episode or a relapse, and are strongly advised. During this period, family members are
frequently under a lot of stress. In addition, when the patient is recovering from an acute
episode, family members and other caregivers are frequently needed to provide support (Keks
et al., 2008).

3.2 Relapse Prevention

The goals of treatment during the stabilisation phase are to reduce stress on the patient
and provide support to reduce the likelihood of relapse, improve the patient's adaptation to
life in the community, facilitate continued symptom reduction and remission consolidation,
and promote the recovery process. If the patient has improved with a particular
pharmaceutical regimen, it is advised that the patient continue on that regimen and be
monitored for at least 6 months (Nor et al., 2020). During this phase, reducing the dose or
stopping the drug too soon may result in a rebound of symptoms and a probable relapse. It's
also crucial to monitor any lingering side effects from the acute period and alter
pharmacotherapy properly to avoid negative side effects that could lead to medication non-
adherence and relapse. Psychosocial therapies are still supportive, but they are likely to be
less regimented and prescriptive than they were in the acute period. Patients and family
members can begin learning about the illness's course and outcome, as well as factors that
impact those outcomes, such as treatment adherence, at this phaseThere must be no gaps in
treatment delivery since individuals are more vulnerable to recurrence following an acute
episode and require assistance in returning to their usual life and activities in the community
(Keks et al., 2008).
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3.3 Stable phase

During the stable phase, the goals of treatment are to ensure that symptom remission
or control is maintained, that the patient's level of functioning and quality of life is
maintained or improved, that increases in symptoms or relapses are effectively treated, and
that adverse treatment effects are monitored (Keks et al., 2008). It is suggested that
undesirable effects be monitored on a regular basis. If the patient agrees, it is beneficial to
maintain strong relationships with people who interact with the patient frequently and are
thus more likely to notice any resurgence of symptoms as well as the occurrence of life
stresses and events that may increase the risk of relapse or obstruct continued functional
recovery. Psychosocial therapies are indicated as a viable supplementary treatment to
pharmacological treatment for most people with schizophrenia in the stable period, and they
may enhance results (Paramita B, Vranda, MN, 2014).

4.0 Psychosocial Intervention

4.1 Family intervention
Between the 1950s and the late 1970s, early social theories of schizophrenia
emphasised the causative impact of dysfunctional child-rearing patterns and disrupted family
communication (Herz et al., 1997). Following that, researchers focused on identifying
elements connected to family contact, as well as family members' views and expectations,
that are likely to impact the course of schizophrenia and other mental and physical problems,
within the context of studies of expressed emotion.

As a result of this approach, family-based therapies have been developed to improve

the family unit's resources in its caring function, ease family load, and adjust family
relationships and affective attitudes that are predictive of relapse (Adams et al., 2000).

4.2 Psychoeducation
Psychoeducation teaches people how to deal with mental health issues, such as how to
manage symptoms and drug side effects, as well as how to avoid relapse. It also includes
advice on the rehabilitation process, such as how to retain a sense of well-being and how to
improve stress management and problem-solving skills. Psychoeducation can be given one-
on-one or in groups, and it can be personalised to the person with a mental illness as well as
family and friends (Orrico-Sánchez et al., 2020).
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In Malaysia, a psychoeducation package is provided that includes topics such as

sickness, treatment, and pharmaceutical side effects, the role of the family, sustaining
wellbeing, and crisis management (Keks et al., 2008). Its goal is to change the patients'
behaviour and attitudes.

4.3 Social skills training

The use of behavioural strategies or learning activities to help patients to develop

instrumental and affiliative skills in areas required to meet the interpersonal, self-care, and
coping demands of community life is referred to as social skills training. The purpose of
social skills training is to correct specific role-functioning deficiencies in patients (Razali et
al., 2000). As a result, rather than being wide, training is targeted, and it is a highly structured
strategy that entails carefully teaching patients certain behaviours that are necessary for social
interaction success. Patients can learn how to manage antipsychotic drugs, detect side effects,
recognise warning signs of relapse, negotiate medical and psychiatric care, convey their
needs to community agencies, and interview for jobs as part of social skills training (Herz et
al., 1997). Social skills training can also help people employ certain social behaviours like
gaze and voice loudness more effectively.

4.4 Cognitive remediation therapy

The cognitive deficiencies associated with schizophrenia are playing an increasingly

important role in explaining the disorder's handicap. These cognitive impairments are
characterised by distractibility, memory issues, a lack of vigilance, attentional deficits, and
limitations in planning and decision making (Adams et al., 2000). Restorative, compensatory,
and environmental methods to treatment have been used in cognitive remediation procedures
to address these issues. The restorative model focuses on removing impairments directly by
correcting underlying cognitive weaknesses. Environmental techniques control the
environment to reduce cognitive demands on patients, whereas compensatory strategies aim
to assist patients "work around" their deficiencies. These cognitive techniques are based on
the assumption that they will not only treat patients directly, but will also improve their
ability to benefit from other therapy approaches and improve social and other elements of
functioning (Scott & Dixon, 1995).
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4.5 Cognitive behavior therapy

Cognitive behaviour therapy was developed for the treatment of depression and
anxiety disorders, but over the last decade, it has been refined for the treatment of
schizophrenia, particularly by clinical investigators in the United Kingdom (Hickling, 2005).
Normal psychological processes can both preserve and weaken the fixity and severity of
psychotic symptoms, including delusions and hallucinations, according to the assumptions of
cognitive behaviour therapy. Some cognitive behaviour therapy entails affirming and
developing natural coping strategies, while the remainder involves gently leading the patient
toward a more rational cognitive perspective on his or her symptom.

4.6 Counseling and supportive psychotheraphy

Time spent talking, client-focused psychotherapy, and a supportive and loving
relationship between therapist and patient in a broader therapeutic context are all common
features of different types of psychotherapy in the treatment and management of
schizophrenia (Adams et al., 2000).

Support entails assisting everyone in the family in coming to grips with a potentially
stigmatising and disabling mental disease, as well as practical day-to-day aid with the added
obstacles that come with having a family member with a significant illness. Patient education
can take several forms, depending on the patient's and family's abilities and interests.
Education can take place in small groups or one-on-one dialogues, or through the use of
videotapes or brochures, or any mix of these methods (Whitehead, 2016).

4.7 Multimodal intervention

Improved self-care and social skills, as well as the development of a strong support
system and network, are all necessary components of successful psychosocial rehabilitation.
As a package of rehabilitation activities, multimodal intervention refers to the use of family
intervention, psychoeducation, social skills training, and CRT at the same time. Evidence
suggests that doctors should promote multimodal smoking cessation therapies for people with
schizophrenia, as they have been shown to be helpful in reducing smoking without increasing
psychiatric symptoms. More research is needed to determine how therapies can improve their
effectiveness in assisting patients in achieving long-term smoking cessation (Keks et al.,
2008).
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4.8 Treatment adherent

Treatment adherence is a well-known issue, but there is still a lack of understanding
on how to enhance it. Treatment non-adherence is still one of the most difficult problems in
psychiatry. Treatment non-adherence was seen in 70-80% of persons with schizophrenia (Nor
et al., 2020).

Non-adherence to prescribed therapies has been linked to psychotic relapses and

hospitalizations in schizophrenia patients, both of which have a poor impact on their clinical
result and quality of life. Antipsychotic medications are also thought to be successful in
treating acute psychosis in the early stages of illness, with a significant reduction in
symptoms in 85 percent of patients, as well as in long-term treatment, with a 60 percent
reduction in the risk of relapses and suicidal conduct. Adherence therapy is a brief and
practical intervention that combines motivational interviewing, psychoeducation, and
cognitive therapy techniques and principles to improve adherence to prescribed medications,
thereby increasing their efficacy in reducing symptoms, improving quality of life, and
reducing the number of relapses (Keks et al., 2008).

5.0 Service Level Intervention

5.1 Community mental health team
The creation of community mental health teams has been a key push toward
community care (CMHT). These teams are at the heart of the community's specialised mental
health services. Nurses, occupational therapists, psychiatrists, psychologists, and social
workers are often members of multidisciplinary teams (Razali et al., 2000). CMHTs seek to
give care that isn't confined to a hospital or institution. People are less unsatisfied with their
care as a result of CMHT management. Although this was largely due to inadequately
provided data, no obvious difference in admission rates, overall clinical outcomes, or
duration of in-patient hospital treatment was detected (Adams et al., 2000).

5.2 Assertive community support

An act team assists a person with schizophrenia in day-to-day activities. Teams are
usually affiliated with a hospital or sponsored by a community organisation that is affiliated
with a nearby hospital. A psychiatrist, peer support worker, registered nurse, social worker,
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occupational therapist, addiction specialist, and vocational specialist may all be members of
the team (Nor et al., 2020).

There may be programmes available to assist people with schizophrenia in living in

their local communities. The services provided differ depending on the location, however
they can include financial, housing, education, employment, and social assistance. Your
treatment team can also assist you in finding the resources you require. Help groups (where
people with similar life experiences congregate and support one another) and places to go in a
crisis are examples of community supports (Whitehead, 2016).

5.3 Day Hospital Care

Day treatment programmes are typically used to provide continued supportive care for
minimally adjusted people with schizophrenia who are nearing the end of the stabilisation
phase and entering the stable phase of their condition. These programmes, which are typically
not time limited, provide structure, support, and treatment programmes to assist patients
avoid relapse and maintain and improve their social functioning (Adams et al., 2000).
Attendance at long-term day treatment was expected to boost engagement, improve clinical
outcomes, and lower readmission rates. A Cochrane review, on the other hand, found no
evidence that day care centres were better or worse than outpatient treatment in terms of
clinical or social outcomes. There was some evidence that outpatient care was more
expensive than day therapy.

5.4 Supported employment

Supported employment is a method of enhancing vocational performance in people
with a variety of disorders, including schizophrenia. Employment programmes assist you in
achieving your goal of returning to work. They may assist you with regaining your work
skills, increasing your self-confidence, and locating positions that match your qualifications
and requirements (Keks et al., 2008). Job assessments, career counselling, aptitude testing,
job search skills, and on-the-job training are all available through these programmes.

5.6 Intensive case management

ICM is a community-based package of care aimed at providing long-term care for
severely mentally ill patients who do not require emergency admission (Coles, 2018).
Intensive Case Management (ICM) emerged from two initial community care models,
Assertive Community Treatment (ACT) and Case Management (CM), in which ICM
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emphasises the importance of a small caseload (fewer than 20) and high-intensity input
(Adams et al., 2000).

Instead of a team, an individual case manager is frequently assigned to provide help

(e.g., a nurse, social worker or occupational therapist). Case managers meet with their clients
on a regular basis and assist in the coordination of care and services (Coles, 2018).

6.0 Conclusion

A generation of research has revealed the tremendous impact of psychosocial

therapies for promoting recovery in patients with schizophrenia over the last three decades.
Supported employment or education, family psychoeducation, cognitive remediation, and
proactive community treatment have all been demonstrated to improve outcomes, although
they are scarce in both developing and developed countries.

According to the study of guidelines, psychosocial treatments in schizophrenia may

be beneficial in the treatment of patients with severe mental illnesses, including
schizophrenia, when used in conjunction with psychopharmacotherapy and psychotherapy.
All of these interventions may address unmet needs in the treatment of psychosis and, in
particular, improve patients' psychosocial functioning in order to aid long-term recovery.
Negative symptoms, as well as personal functioning (social, occupational, and cognitive), are
all addressed. More study on the effectiveness of these interventions is needed, as well as
more resources to deliver psychosocial rehabilitation on a large scale.

The field of non-pharmacological therapy for schizophrenics is mostly unexplored. In

order to quantify meaningful outcomes, including adverse effects, well-designed,
generalisable, randomised, controlled trials involving patients encountered in everyday
practise are required.
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7.0 References

Adams, C., Wilson, P., & Bagnall, A. M. (2000). Psychosocial interventions for
schizophrenia. Quality in Health Care, 9(4), 251–256.
https://doi.org/10.1136/qhc.9.4.251

Ayano, G., Tesfaw, G., & Shumet, S. (2019). The prevalence of schizophrenia and other
psychotic disorders among homeless people: A systematic review and meta-analysis.
BMC Psychiatry, 19(1), 1–14. https://doi.org/10.1186/s12888-019-2361-7

Brown, A. S., & Lau, F. S. (2016). A Review of the Epidemiology of Schizophrenia. In

Handbook of Behavioral Neuroscience (Vol. 23). Elsevier.
https://doi.org/10.1016/B978-0-12-800981-9.00002-X

Coles, B. A. (2018). Intensive Case Management for Severe Mental Illness. Issues in Mental
Health Nursing, 39(2), 195–197. https://doi.org/10.1080/01612840.2017.1355184

Cooke, A. (2014). Understanding Psychosis and Schizophrenia. In The British Psychological

Society. https://www.bps.org.uk/system/files/user-files/Division of Clinical
Psychology/public/understanding_psychosis_-_final_19th_nov_2014.pdf

Herz, M. I., Liberman, R. P., McGlashan, T. H., Lieberman, J. A., Wyatt, R. J., Marder, S. R.,
Wang, P., Allgulander, C., Baldessarini, R. J., Balon, R., Bellack, A. S., Berlin, J.,
Blackington, C. H., Buckley, P., Carlson, D. G., Cott, J., Cournos, F., Desai, P.,
Dickstein, L., … Zonana, H. V. (1997). Practice guideline for the treatment of patients
with schizophrenia. American Journal of Psychiatry, 154(4 SUPPL.), 1–63.
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Hickling, F. W. (2005). The epidemiology of schizophrenia and other common mental health
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Keks, N. A., Hope, J., & Thomas, P. R. (2008). Management of schizophrenia. Medicine
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Nor, Z. M., Idris, I. B., Daud, F., & Rani, N. A. (2020). The psychological well-being of
patients with schizophrenia on follow up clinics in three psychiatric hospitals in
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Orrico-Sánchez, A., López-Lacort, M., Munõz-Quiles, C., Sanfélix-Gimeno, G., & Diéz-
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Paramita B, Vranda, MN, M. D. (2014). Intensive Case Management on a Person with

Treatment Resistant Paranoid Schizophrenia. Artha Journal of Social Science,
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Razali, S. M., Hasanah, C. I., Khan, U. A., & Subramaniam, M. (2000). Psychosocial
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Saraceno, B. (1998). “Nations for mental health: A new who action programme on mental
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Scott, J. E., & Dixon, L. B. (1995). Psychological interventions for schizophrenia.

Schizophrenia Bulletin, 21(4), 621–630. https://doi.org/10.1093/schbul/21.4.621

Whitehead, L. (2016). Supportive Therapy for Schizophrenia. Issues in Mental Health

Nursing, 37(12), 973–974. https://doi.org/10.1080/01612840.2016.1249699

Wu, Y., Kang, R., Yan, Y., Gao, K., Li, Z., Jiang, J., Chi, X., & Xia, L. (2018). Epidemiology
of schizophrenia and risk factors of schizophrenia-associated aggression from 2011 to
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Yoon, C. K., & Aziz, S. A. (2014). A review of schizophrenia research in Malaysia. Medical
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Journal of Malaysia, 69(August), 46–54.