Schizophrenia - Treatment

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There are a broad range of treatment approaches to schizophrenia. Because it is a chronic condition for many, the prognosis is not always good, and much of the treatment is orientated towards the management of symptoms, reducing the worst of their impact and prevention of relapse.

• Schizophrenia - Treatment guidelines
• Schizophrenia - Treatment protocols

• Schizophrenia - Early intervention

• Schizophrenia - Treatment considerations
• Schizophrenia - Evidenced based treatment
• Schizophrenia - Theory based treatment
• Schizophrenia - Team working considerations

• Schizophrenia - Rehabilitation
• Schizophrenia - Continuing care
• Schizophrenia - Followup
• Schizophrenia - Outcome studies
• Schizophrenia - Relapse prevention

Principles of treatment

NICE endorsed the following principles for treating people with schzophrenia:

• Approach sufferers with optimism and empathy
• Provide comprehensive assessment
• Work in partnership with service users

and carers

• Provide comprehensive information
• Use clear language not jargon
• Ask for informed consent before

treatment starts

• Consult advance directives
• Provide comprehensive care plan for

multi-disciplinary approach

• Provide social, group and physical

activities in addition to psychological treatment and medication.

Medication and hospitalization

The first line treatment for schizophrenia is usually the use of antipsychotic medication. The concept of 'curing' schizophrenia is controversial as there are no clear criteria for what might constitute a cure. Therefore, antipsychotic drugs are only thought to provide symptomatic relief from the postive symptoms of psychosis. The newer atypical antipsychotic medications (such as clozapine, risperidone, olanzapine, quetiapine, ziprasidone and aripiprazole) are usually preferred over older typical antipsychotic medications (such as chlorpromazine and haloperidol) due to their favorable side-effect profile. Compared to the typical antipsychotics, the atypicals are associated with a lower incident rate of extrapyramidal side-effects (EPS) and tardive dyskinesia (TD) although they are more likely to induce weight gain and so increase risk for obesity-related diseases⁶². It is still unclear whether newer drugs reduce the chances of developing the rare but potentially life-threatening neuroleptic malignant syndrome (NMS). While the atypical antipsychotics are associated with less EPS and TD than the conventional antipsychotics, some of the agents in this class (especially olanzapine and clozapine) appear to be associated with metabolic side effects such as weight gain, hyperglycemia and hypertriglyceridemia that must be considered when choosing appropriate pharmacotherapy.

Atypical and typical antipsychotics are generally thought to be equivalent for the treatment of the positive symptoms of schizophrenia. It has been suggested by some researchers that the atypicals have some beneficial effects on negative symptoms and cognitive deficits associated with schizophrenia, although the clinical significance of these effects has yet to be established. However, recent reviews have suggested that typical antipsychotics, when dosed conservatively, may have similar effects to atypicals.³⁶

The atypical antipsychotics are much more costly as they are still within patent, whereas the older drugs are available in inexpensive generic forms. Aripiprazole, a drug from a new class of antipsychotic drugs (variously named 'dopamine system stabilizers' or 'partial dopamine agonists'), has recently been developed. Early research suggests that it may be a safe and effective treatment for schizophrenia.³⁷

Hospitalization may occur with severe episodes. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or involuntary commitment). Mental health legislation may also allow people to be treated against their will. However, in many countries such legislation does not exist, or does not have the power to enforce involuntary hospitalization or treatment.

Therapy and community support

Psychotherapy or other forms of talk therapy may be offered, with cognitive behavioral therapy being the most frequently used. This may focus on the direct reduction of the symptoms, or on related aspects, such as issues of self-esteem, social functioning, and insight. Although the results of early trials with cognitive behavioral therapy (CBT) were inconclusive³⁸, more recent reviews suggest that CBT can be an effective treatment for the psychotic symptoms of schizophrenia³⁹.

A relatively new approach has been the use of cognitive remediation therapy, a technique aimed at remediating the neurocognitive deficits sometimes present in schizophrenia. Based on techniques of neuropsychological rehabilitation, early evidence has shown it to be cognitively effective, with some improvements related to measurable changes in brain activation as measured by fMRI.⁴⁰

Electroconvulsive therapy (also known as ECT or 'electroshock therapy') may be used in countries where it is legal. It is not considered a first line treatment but may be prescribed in cases where other treatments have failed. Psychosurgery has now become a rare procedure and is not a recommended treatment for schizophrenia.

Other support services may also be available, such as drop-in centers, visits from members of a 'community mental health team', and patient-led support groups. In recent years the importance of service-user led recovery based movements has grown substantially throughout Europe and America. Groups such as the Hearing Voices Network and more recently, the Paranoia Network, have developed a self-help approach that aims to provide support and assistance outside of the traditional medical model adopted by mainstream psychiatry. By avoiding framing personal experience in terms of criteria for mental illness or mental health, they aim to destigmatize the experience and encourage individual responsibility and a positive self-image.

In many non-Western societies, schizophrenia may be treated with more informal, community-led methods. A particularly sobering thought for Western psychiatry is that the outcome for people diagnosed with schizophrenia in non-Western countries may actually be much better⁴¹ than for people in the West. The reasons for this are still unclear, although cross-cultural studies are being conducted to find out why.

Key texts

Books

• Martindale, B.V., Mueser, K.T., Kuipers, E., Sensky, T., & Green, L. (2003). Psychological treatments for schizophrenia. In S.R. Hirsch & D. Weinberger (Eds.), Schizophrenia (2nd Edition). Oxford, England: Blackwell Scientific Publications (pp. 657-687)

Additional material

Papers

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