Schizophrenia

Description

Treatment

Integrated Approach. Schizophrenia is now officially categorized as a brain disease, not a psychologic disorder, and drug treatment is the primary therapy. Studies indicate, however, that an integrated approach is superior in preventing relapses compared to routine care (drugs plus monitoring and access to rehabilitation programs). In one study, this approach involved the following:

• Motivational interviewing to encourage the patients commitment to change.
• Use of antipsychotic medications (generally atypical or novel antipsychotics) with monitoring.
• Community-based rehabilitation.
• Cognitive-behavioral therapy, which aims to reduce delusions and hallucinations.
• Family interventions.

In the study, relapse rates were 33% in the integrated group and 67% in the group who received routine care.

Whereas treatment of schizophrenia has traditionally focused on alleviating positive and negative symptoms, an important shift is now taking place. Increasingly, physicians are emphasizing patients ability to function -- shop, eat, cook, clean, do laundry, and in some cases, work independently.

Cognitive Remediation Therapy. Experts now recognize that reducing positive and negative symptoms is merely a first step, and that it is also critical to address the fundamental deficits in cognitive function associated with schizophrenia. Patients cognitive function not the absence of positive symptoms -- is the best predictor of their quality of life and independence. Medications do not adequately target complex brain processes such as attention, memory, and learning ability, although some pharmacological agents are currently under study.

Cognitive remediation therapy teaches patients specific strategies for enhancing their attention, memory, and ability to learn. It should be provided by healthcare professionals with medication and other therapies. Mounting evidence is showing that improving patients' ability to learn, remember, and pay attention allows them to better cope with ongoing positive symptoms and lead independent lives. Cognitive remediation therapy should be part of an integrated treatment approach that includes medication, family support, cognitive-behavioral therapy, and community-based rehabilitation.

Unfortunately, such integrated treatment is expensive. Research shows that more than half of individuals with schizophrenia do not even receive routine care. Increased cost cutting in mental health services is making the situation worse. African-Americans, in particular, are less likely to receive effective treatment.

Early Treatment. The earlier schizophrenia is detected and treated, the better the outcome. Patients who receive antipsychotic drugs and other treatments during their first episode are hospitalized less frequently during the following five years and may require less time to control the symptoms than those who do not seek help as quickly. In spite of strong evidence for the positive effects of early treatment, patients usually endure an average of 10 months of serious symptoms before they receive treatment.

Researchers are also trying to determine if intensive early treatment with an atypical agent can prevent progression in people who are at very high risk for a first psychotic episode. In one study, risperidone delayed psychosis by six months, but did not prevent its occurrence. Even a delay in progression to full-blown schizophrenia, however, warrants more research.

Classes of Drugs Used for Schizophrenia

Most drugs that treat schizophrenia work by blocking receptors of the neurotransmitter dopamine, which is thought to play a major role in psychotic symptoms. Although they all have important benefits for schizophrenia, most drugs used for schizophrenia also pose a risk for side effects associated with reduced dopamine. The most disturbing and common side effects are those known as extrapyramidal symptoms, which involve the nerves and muscles controlling movement and coordination.

The following drug classes are generally used for schizophrenia:

• Until recently, the mainstay treatments for schizophrenia have been antipsychotic agents--also called neuroleptic drugs. They include haloperidol (Haldol). Others include chlorpromazine (Thorazine), perphenazine (Trilafon), thioridazine (Mellaril), mesoridazine (Serentil), trifluoperazine (Stelazine), and fluphenazine (Prolixin). These agents have significant side effects, however, particularly extrapyramidal symptoms, which occur in up to 70% of patients taking these medications.
• The atypical, or novel, antipsychotics are proving to be better tolerated than the older antipsychotics and have significantly fewer severe extrapyramidal side effects. They include clozapine (Clozaril) (the first atypical antipsychotic), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon). There is considerable difference among these agents and comparison studies are needed.
• The first third-generation antipsychotic medication is now FDA approved for adults with schizophrenia. Aripiprazole (Abilify, Abilitat) is very selective in that it blocks certain dopamine receptors but not others. Such an effect may reduce the risk for severe side effects associated with dopamine blockade.

Choosing Between Atypical and Standard Antipsychotic Agents. Experts are debating whether older antipsychotics or the new atypicals should be used at the onset of symptoms. The debate includes some of the following issues:

• The atypicals are considerably more expensive than the conventional antipsychotics.
• The atypicals may be more effective than the older drugs, but the additional benefits may be modest for most patients. For example, a 2001 review of 52 trials reported that patients taking the conventional antipsychotics did worse overall than those on the atypicals. When the results were examined closely, however, patients who took low doses of the standard antipsychotics (haloperidol and chlorpromazine) did as well as those on the atypicals.
• Studies are increasingly reporting more rapid action and fewer dropouts from side effects with the new atypicals compared to the older antipsychotics.
• Some atypicals, such as risperidone, may be more effective in preventing relapse than the antipsychotics.
• The older drugs may have a higher than normal risk for sudden death from a cardiac (heart-related) event. The newer atypicals were not compared in this study, however, and most of these pose a higher risk for weight gain, diabetes, and heart disease.

Some experts recommend the following approach:

• Use older antipsychotics at low doses as first-line agents for most patients.
• If the patients either do not respond to the conventional antipsychotics or have severe extrapyramidal effects, they should switch to atypicals.

Treating an Acute or Initial Phase

For the severe, active phase of schizophrenia, injections of an antipsychotic drug are typically given every few hours until the patient is calm. Anti-anxiety agents are also often administered at the same time. Some of the newer atypical agents, such as olanzapine or risperidone, may prove to be as effective as the older antipsychotics with significantly fewer severe side effects. In patients who are being treated for the first time, improvement in psychotic symptoms may be evident within one or two days of treatment, although the full benefit of the drug usually becomes manifested over about six to eight weeks. Thought disturbances tend to abate more gradually.

Maintenance

To reduce the risk of relapse, many physicians recommend that drugs be given daily for at least one year. Atypical agents are increasingly being used as maintenance for those with new-onset psychosis, although the choice of the drug depends on many factors. Side effects and effectiveness vary from individual to individual, and some trial and error adjustments may be necessary when prescribing dosage amounts so that the benefits of treatment outweigh the side effects of the therapy. The physician must monitor the drug effects carefully.

Keeping patients on maintenance therapy, however, is very difficult and many patients stop their medication. Two 2000 studies suggested factors that might affect either positive or negative medication compliance. In one, patients least likely to adhere to their medication regimens had the following:

• Lower occupational status.
• A history of alcohol or drugs abuse.
• Delusions of persecution.
• A history of stopping their medications within the first six months after diagnosis.

In the other 2000 study, patients were more likely to take their medications if they perceived their illness as severe and believed that the drugs would prevent future hospitalizations. It should be noted that neither of these studies indicated whether the medications used were standard antipsychotics or atypical agents. Adding psychotherapy, such as cognitive therapy, to the regimen may help reduce this rate.

Stopping Medications

According to a 2001 study, nearly all patients experience some relapse or worsening of symptoms within two years of stopping maintenance medication. However, in the same study they were closely monitored and medications were reinstated early enough so that only 13% required hospitalization.

Supportive Agents

Antidepressants and anti-anxiety agents may also play an important role in treating the patient with schizophrenia, particularly given the role of depression in the high rates of suicide among these patients.

General Guidelines for Psychologic Treatments

Experts generally agree that current treatment should offer both medical and psychological treatment to the patient. Cognitive-behavioral approaches are showing promise. Support to the family or other caregiver is also important for the long-term improvement of people with schizophrenia.