What are the current treatments of schizophrenia?

What are the current treatments of schizophrenia?

Abstract

I discuss the available treatments for schizophrenia. I comment upon the socio-economic issues arising from living with schizophrenia and the aforementioned treatments. I examine a case study in management of schizophrenia in the NHS. Furthermore, I evaluate two alternative methods to control schizophrenia – one holistic and the other supplementary to a more rigorous regimen. I discuss the impact of schizophrenia on other individuals; especially close family members, as well as wider society. Moreover, the article scrutinizes different antipsychotic drugs and their chemical composition. Finally, I comment upon the validity of two different sources I have used in the creation of this article.

Introduction

Schizophrenia is a mental condition. It is characterised by positive and negative symptoms, where positive symptoms are where there is a shift in disposition, such as hallucinations and delusions, or negative symptoms, where there is dampened emotional and social function, which can manifest itself as ennui or lack of emotion 1. The condition usually manifests itself in adolescence, where it is frequently misdiagnosed as angst or hormonal imbalance. Schizophrenia, like other mental disorders, is expressed in episodes, whereby the intensity of the symptoms increases with the onset of an episode and a regression to the mean when there is no episode; this is the most common form of schizophrenia, and is known as acute schizophrenia 2. The causes of schizophrenia are currently not known, but the key risk factors identified are genetics; brain development; disparity of dopamine and serotonin and birth complications 11. The condition, however can remain dormant until triggers, such as substance abuse and stress 11, can lead to development of schizophrenia.
Hallucinations, a positive symptom, are sensations that an individual experiences which are not the result of external stimulation. These hallucinations can involve perception of any of the senses, but it is reported that hearing is the most common at 50% of cases 35.
Delusions, a positive symptom, are misapprehensions of situations or incorrect assertions ₄. These come often as a result of trying to explain recurring hallucinations. These beliefs are immovable and the subject demonstrates absolute faith in the validity of their explanation 5.

A negative symptom of schizophrenia is blunted affect, whereby the subject shows little or no emotion, especially when there is a call for emotional response e.g. social interaction. This lack of emotion can manifest itself as physical and verbal 6.     Another negative symptom is anhedonia, or an inability to feel pleasure from typical acts e.g. hobbies, sports and relationships. Subjects often cite feeling “emotionally empty” 7. Of all symptoms of schizophrenia, negative symptoms and, more specifically, symptoms that degrade quality of life, are quoted as being most debilitating to subjects 8.

Public perceptions of schizophrenia range from personal experience of looking after family members with the condition, to ignorance of the condition. It is reported by “Only 25 per cent agreed with the statement that “most women who were once patients in a mental hospital can be trusted as babysitters””9. Furthermore, it is suggested that only “34%” of participants in another study acknowledged schizophrenia as a mental condition 8.

Schizophrenia is becoming a major issue in the world. The World Health Organisation states that, globally, “24 million people” suffer from schizophrenia and “90% of people with untreated schizophrenia are in developing countries” 12. From 2001 to 2009, abuse of hallucinogens has increased from 8.2% to 9.3% of 16-59 year olds in England and Wales 13.

Case Study: Care Programme Approach (CPA) – The current solution used by the National Health Service, United Kingdom 

A current treatment is to implement a Care Programme Approach (CPA). This is a plan based on four steps 14:

  1. Assessment – The holistic requirements of the subject are mapped.
  2. Care Plan – Based upon the findings of the assessment, you are assigned a plan to address your condition.
  3. Appointment of a care co-ordinator – You are allocated a keyworker, who is a social worker or nurse, who will oversee your care plan.
  4. Review – Throughout recovery, your progress will be reviewed and the care plan will be adjusted to optimise recovery.

This is a holistic approach to treating schizophrenia, as it affects the mental, physical, emotional and social wellbeing of the subject. Thus, each step in the process addresses each facet of schizophrenia and the subject. As schizophrenia is highly specialised in effect of symptoms on each subject, the CPA is personalised to each subject who presents with schizophrenia to the NHS.

In terms of treating the initial mental side of schizophrenia, antipsychotic drugs are most effective. Antipsychotic drugs manage psychosis (aberrations of the mind) by reducing the severity of the symptoms, such as hallucinations and delusions 15.

There are two types of antipsychotic drugs based upon when they were discovered: typical (also known as first-generation) antipsychotic drugs which were developed in the 1950s 16, and atypical (also known as second-generation) antipsychotic drugs which came later in the 1970s 17. Both types of drugs stop the flow of dopamine in the brain. Atypical drugs also target serotonin receptors in the brain 18.

Typical antipsychotic drugs can be sorted into five categories:

  1. Butyrophenones e.g. Moperone. These compounds have phenyl-1-butanone 19.
  2. Diphenylbutylpiperidine e.g. Pimozide. These compounds inhibit contractions of rat vas deferens that are dependent on concentrations of potassium and calcium at “40-350nM” 20.
  3. Phenothiazines e.g. Pipotiazine. These compounds inhibit dopamine-based communication in the brain by inhibiting receptors 22.
  4. Thioxanthenes e.g. Tiotixene. These compounds work by dampening the D2 receptors in the brain, thereby stopping psychosis from taking hold of the brain 23.
  5. Others e.g. Loxapine. These compounds work in a similar manner to Thioxanthenes, except Loxapine has chlorine, nitrogen and oxygen instead 24.
  6. There are various risks associated with dosages of first-generation antipsychotics. The most common are cramps, dry mouth and weight gain 25. More serious adverse side effects are Tardive dyskinesia, which causes slow but constant involuntary muscle movement 26 and Neuroleptic malignant syndrome, which causes delirium and muscle rigidity, and can be fatal 27.

Atypical antipsychotics cannot be categorised, but the most common are:

  1. Clozapine (Clozaril) – This is widely regarded as the most effective atypical antipsychotic 28. It is given as a last resort, when other drugs have not been successful 29. It works by inhibiting the D1, D2 and D3 receptors 30. However, it has a high binding profile with the 5-HTSA receptor, which is used in serotonin transmission 30, so dosages to the subject are low (between 10-50 mg) 31.
  2. Risperdal – This is also a widely popular drug to use. It is generally used in acute schizophrenia 32. Compared to Clozapine, it has a more benign binding profile, but still having a high binding profile with the 5-HTSA receptor 30. It is not as efficacious as Clozapine 33.
  3. Seroquel (quetiapine) – This is a relatively new drug 34. It has fewer side-effects of a lower severity than the other atypical antipsychotics, with drowsiness being the most common 34. It inhibits dopamine and serotonin levels in the brain 35. It is used only on subjects over the age of 13 36. It has the same binding profile as Risperdal 30.

To treat the social effects of schizophrenia, the CPA calls for the instating a community mental health team (CMHT) to each subject. This team is made up of professionals from a wide background of care fields. They would include social workers, pharmacists, counsellors and psychiatrists 14. The subject will meet with the various members of the CMHT and discuss how they are progressing on with their life and address any misgivings towards their condition. In the most acute of cases, a crisis resolution team (CRT) will take over treatment of the subject at their home and plan to reduce the risk of another crisis occurring. If necessary, detention of the subject in a psychiatric ward will be prescribed.

Implications

Ethical: Compulsory Detention

Sometimes, it is required for the good health of the patient that they are hospitalised in a psychiatric ward. This is done in the interests of the patient. Schizophrenia, especially in the paranoid sub-type, can be very destructive to the subject and their surroundings. This can cause harm to themselves and others, evidenced by recent high-profile murders of people, where the murderer suffered from paranoid schizophrenia 37, and fictional books where the pivotal characters are sufferers of schizophrenia or carers of sufferers 38. Furthermore, the adequate medical needs may only be supplied by a psychiatric ward, so, to maintain an acceptable quality of life, the subject may need to reside in a hospital.

One can also make the case for the Hippocratic right of the patient to self-control over how they proceed in their treatment. Under normal circumstances, when the patient is mentally competent, the doctors would make the most medically sensible decision and present it to the patient. This model, however, does not work when the patient, as with more severe forms of schizophrenia, is not mentally competent to understand fully the treatment option being proposed to them. In conventional wisdom, the decision of the progression of treatment therefore lies with the doctors and wider CPA team. It is difficult to ascertain the true intentions of the patient under these conditions, so the decision is made in full awareness of what is best for the patient. Furthermore, the family of the subject may be brought in to give a more personal account of what the subject may want for themselves. This alternate mode, however, is never an equal substitute for the intentions of the patient themselves, so care and attention must be used in judging when the patient is no longer competent to independently make decisions about their treatment.

It can be argued, however that, especially in the case of compulsory detention, this is being done against the wishes of the subject; whom may wish to live with their family or in their local community. Moreover there is pressure upon the NHS in terms of the low numbers of beds, especially when in the flu season, so, if possible, all subjects should be treated in the community rather than in a highly subscribed hospital 39. Additionally, the subject may also pose a risk to other patients on the ward. This can be damaging to the hospital.

In conclusion, I think we should restrain subjects whose schizophrenia is particularly acute, so they pose less of a danger to themselves and others in the community.

Social: Schizophrenics in the community

Schizophrenics in the community can physically dispel common myths about schizophrenia. Just by observing a schizophrenic in their daily life, many can draw parallels with their own lives. It is also good for the subject, who experiences social interaction and becomes less daunted by it. Moreover, the subject is with his family and friends in the community so will be less burdened by having to live a normal life.

On the other hand, the subject may, from negative symptoms, prefer to be in solitude. This does not improve the subject’s social interaction. Also, the community may shun the subject due to perceived difficulties with dealing with the subject, thus depressing the subject further. Likewise, the subject may pose a real threat to the community, particularly if they possess paranoid schizophrenia, so it may be in the greater utilitarian interest of the community to keep away from the subject.

In conclusion, I think that, if the ability is there and it is safe, the subject should be integrated into the community. This will improve the subject’s ability to cope with social interaction, which aids their recovery.

Implications to other humans

Benefits

Others will have their myths about schizophrenia dispelled. This will mean that the image of schizophrenia will improve from the viewpoint that many have, of dangerous individuals who eschew society and are recluses. Also, through helping people with schizophrenia, people gain a broader view of life for different people. Mental health charities like SMART offer people the opportunity to volunteer and help schizophrenics, which contribute to a better quality of life for both the volunteer and subject.

Due to our current understanding of the symptoms of schizophrenia, the medical establishment has progressed to level where treatment of schizophrenia is successful in the majority of cases. Throughout treatment, the social skills of the subject will gradually improve. This allows them to start living a more normal and socially healthy life. If the subject had a job, they will eventually be able to return to it. This benefits the local economy. The improvement in the social activity of the subject also benefits his family relations. The subject will be able to normalise their relations with the family, which in turn leads to a more stable life. This is better for the family of the subject as they can begin to repair the inevitable damage that a schizophrenic family member would have had on family relations. This leads to a more harmonious relationship and a more fulfilling relationship for the rest of the family with the subject. Moreover, with the friends of the subject, the development of the social skills of the subject will improve relations with the subject. This will also help improve the relations of the subject and the friends. The friends will have a more gratifying time in the company of the subject and will boost their general happiness.

Risks

There have been cases of paranoid schizophrenics murdering people. These cases are very high-profile and so people are exposed to them, whenever they happen. This inflates the risk factor of it happening with any schizophrenic, when the statistics point otherwise. Only “5 to 10%” of schizophrenics engage in any violence 40. Most of this violence is directed towards themselves, and the suicide rate amongst schizophrenics is 4% 41. Mental health is a stigmatised and even taboo topic. Those with mental health issues are often shunned by other people, as they hold biased predispositions of mental people as uncontrollable, violent and emotionless. This attitude stems from media publication of extreme stories about paranoid schizophrenia 59. This also occurs as people generally have very little exposure to people with schizophrenia, the majority of whom are people who can lead normal social lives.

Antipsychotic drugs have side effects. These include parkinsonism and akathisia 57.  These side effects impact upon the social life of the subject with his immediate family and friends, as well as wider society, as the subject will have less social control over themselves. People will be less comfortable being around them and this results more distress for the family and friends, as they feel as though the subject is slipping away. This feeling is compounded if more severe side effects, such as pancreatitis ₅₈ or myocardial infarction 57, are felt as the subject will be hospitalised and will cause more distress to the subject, as they are very ill.

The placebo effect in schizophrenia is more pronounced than in other conditions 60, 61. This is most noticable when second generation antipsychotic drugs are used. Thus, there is a risk of overprescription of the medication, which could lead to severe side effects. This can increase the burden placed on the people around the subject as they witness the side effects in action.

Alternative Solutions

Soteria

Soteria is a service which focuses on the providing a calm environment for the subject. It is a civic service, which, instead of using conventional medicine, gives them a space to exercise their freedom 42. Loren Mosher M.D, the founder of Soteria, started it because he became aware of large proportions of patients required “love and food and understanding, not drugs” 45. Thus, he began an experiment whereby he gave patients autonomy over their care, and compared his results against conventional antipsychotic drugs. The results showed that, for early-stage acute schizophrenia, Soteria was a better treatment than antipsychotic drugs 46.

Soteria relies upon techniques pioneered in Eastern medicine of harmony between man and nature. It uses methods such as yoga and acupuncture to relax the individual. This is done to reduce the severity of the symptoms, such as delusions and hallucinations. This is also achieved through a calm and relaxing environment. The buildings are minimalist, with white walls and little colour to reduce the stimulation of the mind. Other techniques, such as music and art therapy, are used in conjunction with the Eastern methods to relax the mind as much as possible. This is done for up to 3 weeks.

Soteria is utilised by mainstream patients as either an early intervention to prevent more acute episodes of psychosis and mental distress later in the intervention, or as a crisis resolution method for people who are not responding adequately to mainstream antipsychotic treatment. It follows the support recovery model of empowerment of the subject. Soteria is usually used by younger patients (<30 years old). Psychosis, instead than being seen as a biomedical issue, is seen rather as an acute personal crisis of the individual and thus Soteria aims to resolve these using treatments less dependent on medication, as this can distress the subject.

Supplements

It has been noted that people with mental disorders have sharp deficiencies in some vitamins, for example Vitamin D. Also, glycine, an amino acid, has been found to be in short supply in people with mental disorders. Fish oil has been touted as an effective supplement, but this is based solely upon anecdotal evidence, with no studies carried out into the efficacy of it in respect to treating schizophrenia 68.

Glycine improves the efficiency of NMDA receptors in the brain, along with glutamate. It is though that if the glutamate in the brain were to be a better neurotransmitter, it would alleviate some of the symptoms of schizophrenia 47.Glycine is an amino acid which has been researched to alleviate the negative symptoms of schizophrenia.

Another supplement that has been used is DHEA. DHEA stands for Dehydroepiandrosterone is hormone which is secreted naturally by the brain and adrenal glands. It is used to reduce the severity of depression and other negative symptoms 66.  The use of DHEA, however, has been cautioned by many health organisations 66, 67 as DHEA can interact very readily with other chemicals in the brain, such as anastrozole and insulin 67. If used, it is recommended to use 7-keto-DHEA, a by-product of DHEA which is not converted to steroid hormones such as oestrogen 67. It is also recommended to take DHEA under a rigourously planned regimen from your doctor.

Lithium is also used as a supplement. It is primarily used a mood stabilising drug. Lithium in the brain stimulates the production of serotonin. It is especially favoured as, when ingested, spreads widely throughout the nervous system, thus providing a more holistic effect than just on the brain. It is generally accepted that lithium is best used to treat mania, though it is also useful in depression 69. It has also been noticed that lithium decreases the suicide risk of schizophrenics 70. Lithium is generally used as early as possible in schizophrenia, as it is most effective when the symptoms are less severe. Lithium interacts with many other chemicals and medication such as antidepressants and dextromethorphan 69, so should be consumed carefully under guidance.

Inositol is a compound that is found in eukaryotic cells or can be synthesised in the laboratory. It is used to treat negative symptoms of schizophrenia, such as depression. It is believed to work by balancing chemical compositions in the brain to optimum levels 71. This reduces the severity of negative symptoms. Inositol is taken within 4 week cycles, as this is when it produces optimum results 71.

Evaluation of sources

Source 2

  • http://www.nhs.uk/Conditions/Schizophrenia/Pages/Symptoms.aspx
  • Last updated 17/09/12

I believe that the NHS website is a very reliable source. Being the national provider of health in the UK, the NHS aims to educate the public on matters of health. Thus, to do so, it requires professionals in the medical field to check information posted on the website are accurate. The NHS is a reputable source of information on medical matters. Also, the page was updated in 2012, which is only one-and-a-half years ago. Medical knowledge is unlikely to have expanded widely in that timeframe, so the information is accurate. The target audience of the website is the general population, so thus the content must reflect this; namely the simplicity of the language and ease of use. The information conveyed is simple. This is done so that people with limited understanding of medical concepts can grasp the premise of the idea. As the NHS is the outlet for medical information for the national population, it must remain up-to-date with the most recent advances in treatment and illness. As progress in different parts of medicine, such as healthy living and chronic diseases, moves at a rapid pace, the information on the NHS website must be updated as such. The editorial policy of the NHS Choices website 72 states that edits made to the text are made by “doctors” and “National charities with a recognised expertise and specialist interest”. Thus, we can be sure that the information posted on the website is reliable as it from trusted academic sources.

Source 25

  • Tyrer, Peter; Kendall, Tim (2009). “The spurious advance of antipsychotic drug therapy”. The Lancet 373 (9657): 4–5. doi:10.1016/S0140-6736(08)61765-1. PMID 19058841.
  • Publisher: Lancet
  • Published: 05 December 2008

I believe that this paper is an accurate source of information. It was published in the Lancet, a reputable peer-reviewed magazine of topics in science. Professor Peter Tyrer is a Professor of Community Psychiatry at Imperial College London, whilst Professor Tim Kendall is a Professor of English at the University of Exeter. Both looked at the community and medical side of antipsychotic medicine and both are experts in their field, with Professor Tyrer the Founder President of the British & Irish Group for the Study of Personality Disorders.

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