TREATMENT In this section, I discuss general aspects of the treatment of mental health problems: the key principles of effective treatment in psychiatry, which are common to the various different disorders.

Further details about psychological treatments and medication will be found in those chapters.

GOOD OUTLOOK WITH TREATMENT Optimism is important. It helps patients by instilling hope, and is fully justified by research and clinical experience. Most mental illnesses are treatable; and the vast majority of patients do improve from a symptomatic and functional point of view with time and effective management.

Not all of these patients will be completely cured, however; residual symptoms, more prominent, perhaps, at times of adversity, would be common.

On the other hand, complete failure to improve at all is unusual, except in permanent conditions such as learning disability or personality disorder, or progressive degenerative conditions such as dementia. Even here, episodes of worsened symptoms, due for example to a superadded period of depressive illness, may respond well to treatment.

TREATMENT DEPENDS ON CAUSATION- UP TO A POINT... Sometimes, the symptoms are closely connected to a particular cause; an example would be a patient who developed phobic travel anxiety, after a road traffic accident. Treatment focusing on rebuilding confidence in travelling, such as remedial driving lessons, would appeal to commonsense and also good prospects of being effective.

However, the causation of an episode of psychiatric illness does not necessarily dictate the treatment.

For example, a patient with a significant depressive illness with prominent ìbiological featuresî such as loss of sleep and appetite, may well respond well to antidepressant medication, whether or not the illness seems to have followed on from an external trauma such as an accident or from inherent causes.

In this type of presentation, the depressive illness can be seen as a ìfinal common pathwayî, which is capable of being produced by a variety of different causes, or, more likely, a variety of different combinations of sub-causes.

However, common sense of course dictates that causative factors, which have helped to predispose or precipitate or perpetuate the illness, will also need to be dealt with if possible, as part of the overall treatment plan. For example, if a depressive illness is- as is often the case- being perpetuated by alcohol misuse, then these factors will need to be dealt with patient is to make a good recovery.

THERAPEUTIC INTERVIEW This refers to the fact that patients often seem to derive symptomatic benefit simply from having a thorough interview with a sympathetic and experienced psychiatrist, even though the purpose of the interview is for assessment not treatment. Probably, this results from a combination of factors such as:

which the psychiatrist will be doing anyway, as part of the assessment process.
Coupled with the natural tendency to improvement seen in most mental health conditions, significant improvement can result.

For example, a patient may experience panic when approaching the scene of a road traffic accident. They may fear they're going mad. A simple explanation by the assessing psychiatrist of the nature of anxiety symptoms, reassurance that they are not losing their mind, and that the symptoms will be likely to improve if they can "get back on horse" would be likely to be followed by significant improvement in such a case.

The psychiatrist would of course probably be considered to have an ethical obligation as a doctor not to withhold such simple suggestions, whichever side, in a personal injury case, was instructing him.

POTENTIAL PROBLEMS WITH TREATMENT IN REAL LIFE Unfortunately, the situation in practice is often less favourable.

The diagnosis of a mental health problem can be missed:

This can lead to problems presenting late, when they have become entrenched. Likely response is then much less favourable than if they had presented promptly.

COMPONENTS OF AN EFFECTIVE TREATMENT PACKAGE Patients with mild or self-limiting conditions will be dealt with either by primary care or by the patientís own resources (talking to family and friends, religious adviser, workplace counselling, etc).

Patients with more serious or protracted psychiatric conditions will be referred to mental health services. They typically need a "care package" of fairly "low tech" but committed multidisciplinary input in order to get better, including, for example, some or all of the following:

All these services should in theory be available through the patientís Community Mental Health Team. Each citizen is entitled to be referred to their local CMHT, based on their address.

CARE PROGRAMME APPROACH NHS mental health services deliver care according to the care programme approach, CPA. (This applies in England, the arrangements have been different in other parts of the UK).

Essentially, each patient must have a named care coordinator, a written care plan, and regular CPA review meetings.

Patients are either on standard or enhanced CPA; the latter reflects patients receiving more complex care, involving more than one professional and is the key to securing multidisciplinary treatment of the type outlined above.

Here are some details of how CPA is applied, for example, in Hertfordshire and in Blackpool.

FINDING YOUR LOCAL CMHT It is possible to find out the name and address of the team concerned by googling CMHT and the patientís town.

REFERRAL TO CHMT Although the patient can refer himself or can be referred by a concerned relative or friend, it would be more normal for the patient to be referred to the CMHT by their GP. The CMHT will tend to listen to the GP, and the GP's opinion may be crucial in the allocation of scarce resources within the team (for example, limited hours of psychological treatments such as CBT).

CMHT SERVICES IN REALITY Although government has encouraged patients to have high expectations of what they can expect to receive from the national health service in general and from community mental health services in particular, the reality does not always measure up.

As previously indicated, the "core business" of psychiatric services is likely to remain patients with long-term severe mental health problems such skewed to schizophrenia, bipolar affective disorder, etc.

Resources to be limited for other conditions such as depressive illnesses, anxiety disorders, etc, and of course, these tend to be the conditions which are most relevant to many forms of litigation such as personal injury litigation.

A common situation would be a patient with pain and anxiety following injuries received in road traffic accident. the patient stands in need of the package of mental health care outlined above, but because of limited resources, the patient may only receive a limited amount of care, for example, attendance at psychiatric outpatients plus an eight week anxiety management group. The latter would frequently be subject to a further assessment and might involve a delay of several months.

With every such six-month hiatus, the patient's symptoms and disabilities become more entrenched, and the prognosis for improvement, gets less favourable.

This is an undesirable situation, but as someone who works both in community mental health services and in the medicolegal field, I can see the argument from both sides. It is unlikely that there is going to be major increase in resources in the near future in the NHS, and it is therefore necessary to deal with the situation as it is, not as we would all like it to be.

ALTERNATIVES TO NHS TREATMENT If good NHS treatment is available, it can be the best way forward for the patient, especially if the difficulties are complex.

Sometimes, existing NHS treatment can usefully be supplemented by "bolting on." an extra treatment from the private sector, such as for example, a course of cognitive behavioural psychotherapy.

Often however, there will be no alternative but to seek treatment in the independent sector. In finding the right person to refer to, much will obviously depend on knowledge of what is available in the patientís locality. The patient's GP or CMHT may be a very valuable source of information in this regard.

Those funding such treatment should try to avoid reliance on directories and websites; personal recommendation is the key in finding a suitable source of private treatment.