In chronic schizophrenia the diagnosis itself is rarely in doubt.
1. neurological syndromes (e.g. a leukodystrophy) can mimic the clinical picture.
2. A more common problem is to distinguish negative symptoms from depression
3. from the sedative and parkinsonian effects of antipsychotics.
Management of acute schizophrenia
The management of schizophrenia is considered according to the stage of the illness (acute vs chronic) and then by the intervention (physical, psychological, social).
1. Antipsychotics are effective against positive symptoms in a majority of patients over 2–3 weeks. Their onset is gradual; in the early stages, if behaviour is difficult to manage or the patient is very distressed, add a benzodiazepine.
2. Investigate the context of the disorder, as it may give clues as to its development and prognosis. For example, comorbid substance misuse worsens outcome
3. Involve the family. Relatives need support and explanation, and they may be directly involved in therapy.
Management of chronic schizophrenia
After a first episode of schizophrenia, the aims are to prevent relapse, and to optimize the level of functioning. To do this, a combination of pharmacological, psychological and social methods is used.
1. The most important specific intervention is antipsychotic medication, which significantly reduces the rate of relapse in the 2 years after an episode. Even the benefits of psychological and family interventions operate partly by improving treatment adherence.
2. The value of a multidisciplinary approach is apparent from the range of patients’ needs – benefits, accommodation, employment, physical health, etc. The nature of the disorder, especially the effect of negative symptoms, makes people with chronic schizophrenia vulnerable in all these areas.
3. Some patients with schizophrenia remain under the Mental Health Act (in hospital or in the community) for many years.
Modes of treatment
• After a single episode of schizophrenia, antipsychotic medication is continued for 12–24 months. If the person remains well it should then be tailed off because there is little evidence that further medication is beneficial and because of the risk of tardive dyskinesia and other long-term side effects.
• Patients who have had multiple episodes or persistent symptoms usually remain on medication for many years, though the need for it (and the effect of cautious reductions in dose) should remain under regular review.
• Medication is often given in depot form if there are concerns around poor adherence
• Some antipsychotics, such as risperidone, olanzapine, clozapine and amisulpride, have shown greater efficacy than others. The choice of antipsychotic is informed by the presentation of the patient, the patient’s choice, the drug’s side-effect profile and the patient’s treatment history amongst other factors.
• A trial of 6 weeks at an adequate dosage is considered necessary when assessing treatment response, although some response is often seen earlier.
• Clozapine has an important role in patients who are poorly responsive to, or intolerant of, other antipsychotics. It also decreases the risk of suicide and can reduce aggression. It is the treatment of choice where there has been insufficient or no response after two 6-week antipsychotic trials including at least one with an atypical antipsychotic.
• Avoid routine co-administration of anticholinergic agents, or of combinations of antipsychotics.
• Persistent negative symptoms are not improved by antipsychotics, even clozapine. Conversely, it is a myth that the drugs cause them. Similarly, medication has little overall effect, for better or worse, on the cognitive symptoms, although atypical antipsychotics may produce small improvements.
Other physical treatments
1. Benzodiazepines are useful for short-term sedation.
2. Antidepressants should be used in the normal fashion for depression occurring in schizophrenia.
3. Electroconvulsive therapy (ECT) is not effective, except for catatonic stupor.
1. Family approach –EE 2. CBT approach
The nature of chronic schizophrenia means that many patients have problems with daily living. These needs should be identified and met by the multidisciplinary team working through the care programme approach. Assertive outreach teams may be helpful in maintaining close contact with some patients who may have very chaotic lifestyles. Most patients are supported in the community by CMHTs (Community Mental Health Teams).
Accurate estimates for the long-term outcome of schizophrenia are surprisingly hard to obtain
1. because the diagnostic criteria have changed over time
2. because they depend on how recovery is defined.
Taking both symptoms and functioning into account
• one-third of cases have the stereotyped chronic, deteriorating course • one-quarter have a very good outcome
• the remainder have a relapsing, remitting illness.