General principles

In the past few decades, drugs have become the cornerstone of treatment for mental disorders. With the refinement of diagnostic categories and the development of newer drugs it has become important to have guidelines underpinning such treatments.

These guidelines are largely based on assumptions such as the existence of:

• clear-cut diagnostic categories

• effective drug treatments

• disorders that are either life-long or represent life-long vulnerabilities

A further important assumption is that exacerbations and recurrences are unfavourable for patients, their families and society.

In intensive care psychiatry, treatment goals are generally short-term although, where appropriate, long-term goals can also be set. These goals are to reduce symptoms as rapidly as possible; build an alliance for long-term management; educate the patient and their families about the illness, its treatment, and its course (treated and untreated); and lay the groundwork for a return to premorbid levels of functioning.

Effective strategies for achieving these goals include:

• the use of medication in adequate doses for adequate durations before abandoning a drug trial

• avoiding polypharmacy where possible

• optimising long-term drug treatment regimes

• combining drug treatment with psychological treatment strategies, and providing systematic psycho-education for patients and their families

Although the ideal duration of treatment for mental disorders remains debatable, it is generally accepted that almost all acute treatments should continue for at least 6 months, and with disorders such as schizophrenia it may take 18 months, until symptom remission. Furthermore it is recommended that a discrete 6-month period of remission passes before tapering of therapeutic medication commences.