The treatment of schizophrenia

Schizophrenia is often a chronic relapsing psychotic disorder, which primarily affects thought and behaviour. It is characterised by psychotic symptoms including thought disorder (looseness of association, delusions) and often hallucinations (especially auditory hallucinations) that occur relatively early in life. Bleuler (1857-1939) coined the term ‘schizophrenia’, and described the fundamental symptoms of schizophrenia known as the four A’s- autism, association (disturbance of), affect, and ambivalence.

The first psychotic break of schizophrenia usually occurs during adolescence or early adulthood and without treatment the course of the illness is usually downhill. Since the introduction of antipsychotic drugs (APD’s) in the United States in 1954, most patients’ symptoms can be greatly alleviated. Combined with supportive psychotherapy, family therapy, and medication, most patients can be expected to maintain some function in the community.

As the new millennium approaches, psychiatrists are able to become increasingly optimistic about the treatment of schizophrenia and psychoses in general. Ten years ago no new drug had been introduced in nearly a decade and no new drugs were predicted. Recently there have been many new forms of treatment. Stephen Mander (1994) of UCLA, at a meeting of the American Society of Clinical Psychopharmacology said: – “We’re at a time when the treatment of schizophrenia is undergoing a substantial and important change.”

The advent of antipsychotic drugs revolutionised the treatment of schizophrenia. Antipsychotic drugs commonly used in the treatment of schizophrenia are phenothiazines and butyrophenomes. Oral treatment with the first generation of antipsychotics (chloropromazine, haloperidol) has been replaced by a variety of intramuscular depot preparations. Depot injections have the advantage that doses can be given every few weeks by community nurses or practice personnel .

The reduced lapse rate is also another useful factor for depot injections in chronic schizophrenia. Emergency behavioural control of schizophrenia can be achieved by intramuscular injections, but these are best given in hospital, or where admission is imminent. These drugs provide most help to people experiencing the positive symptoms of auditory hallucinations and paranoia, by dampening their responsiveness to irrelevant stimuli (Lenzenweger et al, 1989). Schizophrenia patients with the negative symptoms of apathy and withdrawal often do not respond well to these antipsychotic drugs. A newer drug, clozapine, does sometimes enable “awakenings” in such people.

The choice of the antipsychotic drug depends to a large extent on their side effects. Antipsychotics such as Thorazine are powerful drugs that can produce sluggishness, tremors, and twitches similar to those of Parkinson’s disease (Kaplan and Saddock, 1989). Clozapine has few such side effects. What an effective dose for some people may be an overdose for others. Asians, for example, seem to require lower doses than Caucasians (Holden, 1991). The therapist has to be very careful in relation to the dosage, as there is a fine line between relieving the symptoms and causing extremely unpleasant side effects.

Over the years a number of factors led to the use of increasingly high doses of APD’s to treat patients with schizophrenia. These included the widespread use of high- potency APD’s, and the desire to accelerate the time course of antipsychotic treatment response. As a result, patients were often treated with doses higher than necessary for optimal treatment response. Treatment studies showed that these patients (treated with higher doses) do not gain additional therapeutic benefits but do experience more side effects (Van Putten et al, 1990).

Kinon et al, 1993, demonstrated that among patients who failed to respond to an initial 4 week course of APD treatment, those who were treated with a higher dose of the same drug did no better than patients who continued to receive their original dosage for an additional 4 weeks. These findings show that once the therapeutic APD dose is reached dose manipulations may not be accomplishing much more than increasing the likelihood of side effects.

There has been reasonable evidence that biochemical abnormalities typically play an important role in the development of schizophrenia. It has been claimed (more specifically), that numerous neurons in the brains of schizophrenics are over sensitive to the transmitter, dopamine. Therefore it can be reasonably presumed that drugs that block dopamine should alleviate the symptoms of schizophrenia. The group of drugs, phenothiazines, have been found to block dopamine. This drug has, as expected, been found to reduce many of the symptoms of schizophrenia, including hallucinations and thought disorders. The phenothiazine drugs producing the greatest dopamine blockade tend to have the most beneficial effects (Snyder, 1976).

However, it has been put forward that the drug does not cause a blockade, but simply acts as a sedative, which calms the patient down. But this theory is not very likely, as powerful sedatives such as phenobarbital are much less affective in reducing the symptoms of schizophrenia. If phenothiazine acts primarily on the symptoms of schizophrenia by means of a dopamine blockade, then drugs should have little or no effect on any symptoms that do not depend on dopamine activity. Klein and Davis, 1969, found that the drug has very little effect on non- schizophrenic symptoms such as guilt, anxiety, and depression.

Although the drug, phenothiazine is used widely, there are some side- effects. These effects include blurred vision, grogginess, muscular rigidity, drooling, and a shuffling gait. These unpleasant side effects mean that many patients do not like taking the drug. Other drugs can reduce some of these side effects, but many cannot. The APA guideline for the Treatment of Patients with Schizophrenia1 highlights antipsychotic medication as the instrumental part of schizophrenia treatment.

Particularly stressed are the newer antipsychotic medications, such as risperidone and olanzapine, which frequently relieve the symptom of schizophrenia better than the old medications, and often with fewer side effects. Clozapine, also a newer, fairly successful medication, is supported as a second- line drug since it requires weekly blood draws to protect against the risk of a fatal blood disorder. Dr. Stephen Marder of UCLA noted that the newer drugs such as clozapine have a much wider margin of safety than the older drugs, and they cause fewer extrapyramidal symptoms.

Electroconvulsive Therapy (ECT) has a higher success rate for severe depression than any other form of treatment. It has also been shown to be an effective form of treatment for schizophrenia. ECT is usually given 3 times a week. A patient may require as few as 3 or 4 treatments or as many as 12 to 15. Once the patient’s more or less back to their normal level of functioning, 1 or 2 additional treatments are given to prevent relapse. ECT involves a very small current being passed through the brain, activating it and producing a seizure. Because as many as 20 to 50% of the people who respond well to ECT relapse within 6 months, a maintenance of treatment of ECT at monthly or 6 week intervals might be advisable.

There are certainly some patients who find ECT as terrifying and shameful, and some report distress about persistent memory loss (Dr. Demitris Popolos). However an article entitled “Are Patients Shocked by ECT?” reported on interviews with 72 consecutive patients treated with ECT. The patients were asked whether they were frightened or angered by the experience, how they looked back on the treatment, and whether they would do it again. Of the patients interviewed, 54% considered a trip to the dentist more distressing, many praised the treatment, and 81% said they would agree to have ECT again.

According to the APA guideline for the Treatment of Patients with Schizophrenia, routine doctor’s visits and a standard medication are not enough. The APA recommends treating each patient on an individual basis, with emphasis on medication management and continuing care specific to each patient’s needs. In this way and with the help of supportive people, hundreds of thousands of schizophrenia patients who had been consigned to the back wards of mental hospitals have returned to jobs and near-normal lives.

BIBLIOGRAPHY

Internet sites:- Electroconvulsive Therapy by Dr.Demitris Popolos Psychiatric Times- Treatment of Schizophrenia: Trends and Outlook by Jeffrey. A.Lieberman, M.D. The Schizophrenia Homepage- APA guidelines for the treatment of patients with schizophrenia. The Schizophrenia Homepage- New era in the treatment of schizophrenia envisioned A review of Schizophrenia by Dr B Green, consultant Psychiatrist, UK.

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