Principles of treatment and management Preliminaries

Medically, 'treatment' and 'management' are often used synonymously. In dealing with the complexities of schizophrenia, however, 'treatment', with its narrower, patient-orientated, and medical connotations, is best restricted to primarily psychopharmacological issues targeted on dimensions of efficacy while the latter is more appropriate to broader care issues. The views expressed here are the authors' own and relate to work within the United Kingdom context. They will not be shared by all others, and the strategies we suggest will not always be appropriate in the very different circumstances of some other countries.

The doctor confronted with a patient believed to be acutely psychotic must address three preliminary questions.

1. Can the clinical situation be dealt with informally or are compulsory powers required?

2. Does the patient require admission or can they be managed as an outpatient?

3. Must medication be started immediately or is it legitimate to observe the evolution of the illness over time?

The answer to the first question will depend on a thorough risk assessment. The latter has already been addressed. Research and clinical experience indicate that not all acutely ill patients will require admission, although in certain scenarios admission should be a priority ( Tab.'®... .3).

Table 3 Considerations in relation to admission policies in patients with acute schizophrenia

Admission provides the psychiatrist with a number of advantages, including the following:

• adequate observation to delineate the extent of symptomatology

• comprehensive assessment of risk

• establishing a solid therapeutic alliance

• stabilization of medication in a supervised environment in which rapid changes of plan can be implemented swiftly and safely

• ready opportunities for avoiding or treating psychiatric emergencies.

However, there is an important additional advantage from the patient's, and often the carer's, point of view: inpatient facilities can provide that security and support which define the cardinal elements of 'asylum'.

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