By Dr Nathan Gibson, Chief Psychiatrist of Western Australia

Psychotic disorders are a diverse cohort of illnesses affecting the way we think, perceive, feel and engage with the community.

Evidence shows that psychotic illness is still more stigmatised than anxiety and depression, which is a tremendous barrier to care. Clinicians have a role to stamp out stigma starting with the language we use. Is it respectful, or shaming and rejecting?

Hope of finding a single gene causation of psychosis (particularly schizophrenia) has faded. The cause of psychosis often remains multifactorial. Important as a potential focus for treatment, there is now solid evidence for significant personal trauma (e.g. sexual and physical abuse) as a contributory factor for psychosis in some individuals.

Methamphetamine-related psychosis has featured in the WA media. Those who use methamphetamine are 11 times more likely to have a psychotic illness than the general community and people with a psychotic illness are twice as likely to be dependent on alcohol or other drugs. Psychoses associated with methamphetamine and other substances are valid and very serious psychoses. They are often extremely challenging to manage, and require assertive, rigorous follow-up by both mental health services and primary care.

Individuals with schizophrenia are likely to die 20 years prematurely. Suicide is not the main cause. It is mostly due to cardiovascular and other diseases, which is a massive public health challenge. Overweight, hyperlipidaemia, diabetes mellitus, hypertension and smoking – individuals with schizophrenia and other psychoses have a right to assertive physical screening and interventions.

Management of psychotic disorders is not just about antipsychotics such as risperidone and aripiprazole. They remain a critical, evidence-based component of care but quality care also requires a broader focus on the needs of the individual. Strategies such as cognitive behavioural therapy, family psycho-education and psychosocial supports are evidence-based and equally important.

The ‘Recovery’ paradigm is a worldwide movement that focuses on those with significant mental illness. It is not necessarily about recovery from symptoms, but it’s about fostering hope, patient-focused goals of care and assisting individuals to lead meaningful lives that may contribute to the community. Symptom control is not always the best marker of a good outcome, but self-determination and quality of life must be key in the holistic health picture. It’s nothing new for us: good clinical care has always put the patient at the centre.

Psychoses are complex and extremely serious but there is good evidence for us to be authentically hopeful for our patients with psychotic illness.

Key messages

  • Personal trauma may be a factor in psychotic illness.
  • Psychotic illness due to substances requires assertive follow-up.
  • Physical care in psychotic illness is a major priority.
  • Foster hope – the majority of people do well.

Author competing interests: nil relevant disclosures. Questions? Contact the editor.

Further reading: www.ranzcp.org/Files/Resources/Publications/CPG/Clinician/CPG_Clinician_Full_Schizophrenia-pdf.aspx

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