Acute Mental Illness

The discussion should begin with a discussion from a physician's perspective of the importance of distinguishing acute and chronic phases of mental illness.

While mental disorders are largely chronic in nature, many patients experience cycles of relapse and remission over extended periods. Thus, one of the most important aspects of mental illness is the need for effective treatment strategies during both the acute and chronic phases. Although physicians and other mental health care professionals usually try to consider all aspects of patient care when designing a treatment plan, treatment goals may differ during acute and chronic phases. What’s more, although one cornerstone to treatment success is continuity between inpatient and outpatient treatment, the field of psychiatry has not completely integrated both components.

What are the Acute Episodes of Mental Illness?

When a person is referred to a psychiatrist or other mental health care provider because of a recent change from previous patterns of behavior, the clinician often must begin by identifying the nature of the acute episode. In general, the term "acute episode" refers to symptoms that are serious and have a short course. In the case of some mental disorders, including schizophrenia, a person's first obvious sign of illness may be the acute appearance of psychotic symptoms, called a "first break." However, previously stable chronic patients may also have a relapse and develop acute symptoms. Thus, an acute episode can fall into one of two categories:

• patients with a first-time diagnosis of a mental disorder
• patients with an acute exacerbation of a previously diagnosed mental disorder

When patients experience a first-time acute episode of mental illness, physicians often request information from the patient’s friends or family since they are usually most knowledgeable about whether or not the patient’s behavior is aberrant. Based on these reports and the physician’s own clinical examination, the physician can then refer to the guidelines often used for diagnosing mental disorders, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). The DSM-IV-TR typically requires that a certain number of symptoms or behaviors be present for a specified period of time. The manual does not list specific criteria for diagnosing an acute episode, but it does provide rich descriptions for classifying the long-term course of various mental illnesses.

Despite the availability of diagnostic tools such as the DSM-IV-TR, a number of barriers can prevent a person with a mental disorder from being diagnosed and treated, even during or shortly after an acute episode. For example, those who are unable to understand that their behavior is abnormal may resist seeing a doctor and thereby avoid diagnosis and treatment. Others who are willing to be diagnosed may nevertheless refuse to start or adhere to the prescribed therapy. Another important barrier to early diagnosis and treatment is the fear of stigmatization. Finally, other factors, such as where the individual lives (e.g., in a rural versus an urban area) can affect how quickly a mental disorder is recognized and treated.

What are the common treatment approaches during an Acute Episode for patients with mental illness?

Despite many similarities in the treatment strategy for patients with acute and chronic mental illness, several principles are particularly important during an acute episode:

• patients may need to be protected from themselves and from others, sometimes through 24-hour-per-day monitoring or hospitalization
• patients must be assessed for immediately treatable causes of the acute episode, such as an ingested toxin or drug overdose
• patients currently on medication must be assessed for the possibility of nonadherence, leading to the current symptoms
• patients already being treated for a serious disorder, such as schizophrenia, may need additional medication or dosing adjustments during the acute episode