Treatment

Schizophrenia is now officially categorized as a brain disease, not a psychological disorder, and drug treatment is the primary therapy. Studies indicate, however, that an integrated approach better prevents relapses than routine care (medication, monitoring, and access to rehabilitation programs).

Integrated Approach. An integrated approach may include:

• Motivational interviewing to encourage the patients’ commitment to change
• Use of antipsychotic medications (generally atypical or novel antipsychotics) with monitoring
• Community-based rehabilitation and social skills training
• Family psychotherapy
• Cognitive-behavioral therapy to reduce delusions and hallucinations

A 2005 study found that an integrated approach significantly reduced psychotic symptoms. These improvements lasted for several years after treatment.

Treatment of schizophrenia has traditionally focused on decreasing patients’ negative symptoms. Today, an important shift is now taking place. Doctors are now emphasizing patients’ ability to function -- shop, eat, cook, clean, do laundry, and in some cases, work independently.

Cognitive Remediation Therapy. Cognitive remediation therapy teaches patients specific strategies for enhancing their attention, memory, and ability to learn. More and more 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.

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 admitted to the hospital less often during the following 5 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 do not receive treatment until after 10 months of serious symptoms.

Researchers are trying to determine if intensive early treatment with a second generation antipsychotic (also known as an atypical drug) can prevent progression in people who are at very high risk for a first psychotic episode. In one study, risperidone delayed psychosis by 6 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. Dopamine is thought to play a major role in psychotic symptoms. Although the drugs used to treat schizophrenia have important benefits, they may also cause side effects. 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:

• Antipsychotic or neuroleptic drugs. Until recently, these have been the mainstay treatments for schizophrenia. Such drugs include haloperidol (Haldol), chlorpromazine (Thorazine), perphenazine (Trilafon), thioridazine (Mellaril), mesoridazine (Serentil), trifluoperazine (Stelazine), and fluphenazine (Prolixin). Side effects involving the nerves and muscle movement and coordination occur in up to 70% of patients.
• Second generation antipsychotics, also called atypicals. These are proving to be better tolerated than the older antipsychotics and have significantly fewer severe side effects. Types include clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon).
• Third generation antipsychotics. Aripiprazole (Abilify, Abilitat) is the first “third-generation” antipsychotic medication is approved for adults with schizophrenia. It is a selective dopamine receptor blocker. That means it does not block other receptors. Such an effect may reduce the risk for severe side effects.

Which Type of Drug to Choose. Experts have debated whether older antipsychotics or the new atypicals should be used to treat schizophrenia symptoms. The debate includes some of the following issues:

• Atypicals are considerably more expensive than the conventional antipsychotics.
• The atypicals may work better than the older drugs, but the additional benefits may be modest for most patients.
• The older drugs may cause more neurological problems including muscle stiffness and tremors. They may also increase the risk for sudden death from a cardiac (heart-related) event. However, many of the newer atypicals pose a higher risk for weight gain, which can lead to diabetes as well as heart disease.

A landmark 2005 study published in the New England Journal of Medicine compared the older antipsychotic drug perphenazine with four newer ones: Olanzapine, quetiapine, risperidone, and ziprasidone. This study was extremely important because it was the first large clinical trial to evaluate whether atypical antipsychotics really do work better than standard antipsychotics.

The study found little difference between the old and new drugs. They all worked fairly well in controlling schizophrenia symptoms. However, nearly three-quarters of the patients stopped taking their assigned drug before the end of the 18-month trial and switched to another drug. Fewer patients stopped taking olanzapine, even though it caused more weight gain (an average of 2 pounds per month) than the other drugs. Other side effects increase the risk of diabetes and heart disease.

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 drugs are also often administered at the same time. Some of the newer atypical drugs, 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 1 or 2 days of treatment, although the full benefit of the drug usually becomes manifested over about 6 to 8 weeks. Thought disturbances tend to abate more gradually.

Maintenance

To reduce the risk of relapse, many doctors recommend that drugs be given daily for at least 1 year. Atypical drugs 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 doctor 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 6 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 drugs. 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 2 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 Drugs

Antidepressants and anti-anxiety drugs 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 Psychological 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.