Schizophrenia

Treatment

There is no cure for schizophrenia and as a result, the disease is incorrectly perceived as an untreatable, chronic debilitating disease with a poor prognosis. Unfortunately, this may be true in up to 35% of people who have a schizophrenic disorder, but for many, the disease is far less severe and with the correct treatment, they can lead productive and fulfilling lives. Antipsychotic drugs are available to control acute psychosis, but unfortunately many of the older agents are associated with a high rate of undesirable side effects. However, this is being improved by the newer antipsychotic drugs. Effective treatment of schizophrenia extends well beyond drug therapy and includes psychotherapy and support from family and friends. Up to 20% of people who experience a psychotic episode may not experience any further episodes and will not require lifelong treatment.

Drug therapy

Antipsychotic medications are used to relieve the symptoms of schizophrenia; they fall broadly into two classes:

People with schizophrenia have an excess of the neurotransmitters dopamine and serotonin: the conventional, first-generation antipsychotics are dopamine antagonists whilst the newer, atypical, second-generation antipsychotics are dopamine and serotonin antagonists. These drugs stop the neurotransmitter binding to its receptor  and hence its subsequent actions. The first-generation antipsychotics are associated with a high risk of side effects, which can be inconvenient, disabling and dangerous and occur in 40-50% of those treated. Second-generation antipsychotics are generally more widely prescribed to treat schizophrenia, as they cause fewer side effects. Despite the superiority of the second-generation antipsychotics, only approximately 30% of people who experience a psychotic episode are treated with these drugs in Europe.

Schizophrenia can be characterised by three phases: acute, stabilisation and maintenance and treatment is tailored accordingly.

Acute
The acute phase of treatment is from the start of the psychotic episode until remission or significant improvement of the psychotic symptoms. This usually takes 4 to 6 weeks. During this short period, people with schizophrenia are often admitted to psychiatric hospitals or enrolled in a day care hospital programme, and are treated with the optimal dose of antipsychotic medication and may be sedated initially.

Stabilisation
This phase lasts from 6 weeks to 6 months after the onset of an acute episode and during this time, acute psychotic symptoms decrease in severity. The affected individual is discharged from hospital and antipsychotic medication is stabilised at a dose where the side effects are minimised while preventing recurrence of the psychotic symptoms. Psychotherapy should be started at this phase.

Maintenance
After 6 months of antipsychotic treatment symptoms should be relatively stable and the psychiatrist should begin to reduce the dose of antipsychotic medication to a level that still prevents the reoccurrence of a psychotic episode. Continued support is needed during this time and psychoeducation and compliance-improving measures are very important.

Up to 13% of people with schizophrenia commit suicide. It is therefore essential that people with schizophrenia receive psychotherapy and are strongly supported by their family and friends. Medication, stress management and education are important factors contributing to effective disease treatment.

Psychosocial treatments

Psychosocial treatments are vital forms of therapy and should be implemented alongside medication. Psychosocial treatments include:

Psychotherapy - individual and group therapies that focus on practical life problems associated with schizophrenia, eg life skills training.

Family interventions - programmes that educate families about schizophrenia, provide support and crisis intervention and offer training in communication.

Psychosocial rehabilitation and skills development - training that teaches people verbal and nonverbal interpersonal skills, such as listening and conversation skills and medication management, to allow them to live successfully in the community.

Coping and self-monitoring - training to enable people to manage distressing symptoms and the effects of their illness.

Vocational rehabilitation - training on employment, self-esteem and personal purpose in life to teach people with schizophrenia the values of employment.