Schizophrenia is a devastating psychiatric condition. It is a major cause of disability with huge human and financial costs. In the United States alone, direct medical expenditures are more than $30 billion per year. The indirect costs to society and family members have been estimated at another $30 billion yearly.
Two important features of schizophrenia are psychosis and what psychiatrists call negative symptoms. Psychosis is the inability to recognize reality — for example, delusions (false beliefs) and hallucinations (false perceptions). The negative symptoms of schizophrenia include:
- A restriction of emotional range
- A tendency to be inexpressive
- The inability to be active and productive
These problems almost always result in significant functional decline.
After many years of enthusiasm about new medications to treat schizophrenia and other types of psychoses, recent attention has focused on the limits to their effectiveness and their troubling side effects. But the medications, even if they are a key to controlling the most dramatic psychotic symptoms, turn out to be just one part of the proper treatment for this disease.
As devastating as schizophrenia is, the problem for the schizophrenia sufferer is compounded by the stigma and public misunderstanding of the illness. As a result, it often takes too long for people to recognize the illness, and good treatment is hard to find even when the diagnosis is made.
Let's look at what experts think these patients with schizophrenia need and why it's so important for them to get that help early on.
Why Is Early Treatment Better?
Early treatment is better, because affected patients respond better to treatment during their first psychotic episode. Also, the greatest decline in functioning is seen within the first few years of making a diagnosis. Symptoms get worse and are harder to treat with each subsequent episode.
Unfortunately, during a psychotic episode, patients may not be aware of the problem and may be frightened to go for help. If the situation becomes bad enough, they may be forced to go to a hospital. The use of force may frighten them away from getting further treatment. This leads to a cycle of running away from help, rather than toward it.
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What Does Good Treatment Look Like?
Antipsychotic drugs (for example, newer agents like risperidone, olanzapine, ziprasidone, quetiapine or aripiprazole, and older ones like haloperidol) are the mainstay for reducing psychotic symptoms, and they are most effective during the first psychotic episode. Half of patients have symptom relief within three months and three-quarters are better within six months.
Unfortunately, side effects, such as weight gain or sedation, can be very troubling. Many patients stop taking the drugs. And many people with schizophrenia, even if they continue their medication, remain psychotic. They also are more prone to depression, anxiety and substance abuse. Suicide risk is also higher than average in this population. All of these problems can be dealt with much more effectively if the individual has a close working relationship with a team of professionals.
Because of this complex set of issues, many experts now advocate a specialized system of care designed specifically to deal with the typical problems of schizophrenia. According to the model, teams of mental health professionals in the community reach out to families with intense education and support.
They don't just provide medication. Members of the team help families understand what to expect from medications and respond immediately if uncomfortable side effects occur. They also provide:
- Timely psychotherapy to assist the person in adapting to the illness
- Occupational therapy to improve functioning, and
- Social services to deal with financial support or housing
Crisis centers and hospitalization are available in an emergency.
The first aim is to eliminate psychotic symptoms. At the same time, psychosocial treatment is aimed at helping the person return to better functioning at home, work or school.
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How Effective Is Psychosocial Treatment?
In recent years, centers in North America and Europe have studied the effectiveness of "multi-element" psychosocial approaches. Patients enrolled in these special programs have seen a reduction in symptoms and fewer hospitalizations than average. Their functioning and quality of life also seem to improve.
It is very difficult for researchers to subject these approaches to the truest test of their effectiveness — controlled studies, in which similar groups of patients are assigned randomly to different treatments, and the results are compared. Because hard evidence of their value is limited, these programs remain a tough sell: They are expensive to run and cumbersome to maintain. Some argue that, since specialized approaches have not yet been proven effective by the highest standard of science, it is unreasonable to organize complex systems of care for these patients.
Fortunately, proof is beginning to appear. In a recent paper in the British Journal of Psychiatry, about 150 patients with psychosis were treated either by a specialized team or by the usual mental health system. The specialized mental health team provided one-stop shopping for the patient's mental health and social service needs, including medication management, psychotherapy, vocational assistance and family support.
After 18 months, patients in both treatment groups had similar reductions in symptoms. But patients treated by the specialized team had better social relationships, and were functioning at a higher level than the patients treated in the usual system. They were more satisfied with their treatment, reported a higher quality of life, and were more likely to continue their prescribed medication. They had fewer days in hospital and fewer harmful events.
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Where Is Schizophrenia Treatment Headed?
Maybe it is too soon to reorganize the entire mental health system. But current information can still help clinicians improve care. After all, the principles that guide specialized schizophrenia treatment teams are the same principles that guide good mental health care for all patients. The prescription of medication alone is rarely enough. It makes sense to offer patients a trusting rapport with their clinicians, and an opportunity to discuss their functioning and the quality of their relationships.
Specialized treatment in the early phases of schizophrenia may be nothing more than a psychosocial approach that takes into account their special needs, especially with regard to their tendency toward poor functioning. The United Kingdom, Canada, Denmark, Norway and Australia have all worked on early intervention programs for patients with schizophrenia. Some research centers in the United States are doing the same. As their efforts are studied, we should know more about what kinds of psychosocial interventions are most helpful to people with schizophrenia.
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Michael Craig Miller, M.D., is the editor in chief of the Harvard Mental Health Letter. He is also associate physician at Beth Israel Deaconess Medical Center and assistant professor at Harvard Medical School. He has been practicing psychiatry for over 25 years at Beth Israel Deaconess Medical Center. He teaches in the Harvard Longwood Psychiatry Residency Program.
