Community case management for mental illness.

These case vignettes clearly illustrate the complexity which is modern psychiatric case management. In the case of Mr D, one of the salient facets of case management was medication monitoring in the context of the introduction of a new depot injection. This was a function in which nursing knowledge of medications and their side effects was undoubtedly advantageous. Any adverse experience with medication is likely to have negative ramifications regarding future compliance. Therefore, a nurse case manager is ideally suited to provide the appropriate information on psychotropic medications and to confidently answer most questions about these medications, and promptly identify any possible emerging side effects. In the case of Mr X, the management began with a practical and crisis focus involving suicide prevention. This developed into supportive psychotherapy, which required sensitive but proactive intervention and, ultimately, significant counselling skills. Mr L's case management had a different focus again, characterised by the development of a new and comprehensive case formulation and a creative nurturing of an individual's identified strength in music. The vignettes not only serve to highlight the well-established heterogeneity of mental illness, but they also importantly illuminate the heterogeneity of case management, a reality obscured in the descriptions of case management models which perhaps misleadingly have given the impression of the process as being merely a number of clearly defined tasks or functions. In actual fact, though the coordination of care appears to represent a common feature, the case management relationship remains an ever changing one, with adaptability, refined clinical skills and practical problem solving skills being the essential requisites of an effective case manager. Therefore, attempts to present this important activity in terms of any one model seem to miss the point. For the consumers of psychiatric services, the experience of case management is unique, and for case managers too the experience with each 'case managed' individual is unique. This uniqueness, together with the diverse skills involved in case management needs to be acknowledged. One way of acknowledging this is, as demonstrated, in the presentation of case vignettes and comprehensive case studies. As psychiatric nursing moves toward the new millennium, case management offers psychiatric nurses (as the clinician most often cast in the role of case manager), the exciting opportunity to extend their role and responsibilities. More importantly, it offers mental health care workers the opportunity to be more actively involved in the liberation of psychiatric patients from a situation of custodial care to a new life in the community.