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How to treatment of schizophrenia

How to treatment of schizophrenia?There are a lots of methods of treatment of schizophrenia. There are many patients a doctor can be selected under the guidance and advice more appropriate treatment options to modulating their condition.

Antipsychotic medication

Most people diagnosed with schizophrenia receive some form of medication, although dosages may be reduced or even discontinued during periods of remission. Chlorpromazine, haloperidol and clozapine are three of the most commonly used drugs (see Chapter 4 for a review of their mode of action and effectiveness). Their most striking effect is one of sedation. They also have a direct effect on hallucinations and delusions, although their effectiveness varies markedly between individuals. Chlorpromazine and haloperidol seem to affect only the positive symptoms of schizophrenia: clozapine, an atypical neuroleptic, is more successful in treating both positive and negative symptoms, and is often effective when other treatments fail (Essali et al. 2009). Antipsychotic medication has been so successful in treating people with schizophrenia that their typical hospital stay during an acute episode has declined to less than 13 days, when formerly it was months, years, even a lifetime. Appropriate medication also lies at the heart of the relatively good levels of relapse (10 per cent in the fi rst year) reported earlier in the chapter. Nevertheless, they appear to delay relapse rather than prevent it.

The use of antipsychotic drugs is not without problems. They have a variety of side-effects that frequently lead those receiving them to minimize or stop their use. Side-effects of chlorpromazine, for example, include a dryness of mouth and throat, drowsiness, visual disturbances, weight gain or loss, skin sensitivity to sunlight, constipation and depression. More problematic, however, are what are known as extrapyramidal symptoms. These include the symptoms of Parkinsonism and tardive dyskinesia, which have been estimated to affect over a quarter of individuals who receive medium- to long-term neuroleptic treatment. Treatment by clozapine or other atypical neuroleptics does not carry this risk, but those who receive it may be at risk of a condition known as agranulocytosis, which results in signifi cant impairment of the immune system and can result in death. In addition, although psychomotor symptoms may not occur, people on clozapine experience more drowsiness, hypersalivation or temperature increase, than those given conventional neuroleptics. Despite this, clozapine is the preferred medication (Essali et al. 2009). Adherence to antipsychotic drug regimes can be as low as 25 per cent among people living in the community (Donohue et al. 2001). This does not seem to be associated with sociodemographic variables, severity of the disorder, or even the extent to which people experience extrapyramidal symptoms. Instead, low adherence seems to be related to attitudes towards medication, expectations of drug effectiveness, available social support, and the quality of the therapeutic alliance. Poor memory may contribute to accidental adherence. Strategies to maximize adherence include education, developing a high quality therapeutic alliance, and the use of memory aids for those with a poor memory. Depot injections may also be of benefi t, as these have a relatively long active therapeutic life, and involve the client in less day-to-day decisions about taking oral medication. One relatively new strategy is known as motivational interviewing (Miller and Rollnick 2002). This approach encourages the client to choose whether or not to take their medication as a result of a careful exploration of the costs and benefi ts of doing so. This gives a degree of control to the client, maintains or improves the therapeutic alliance as the therapist is not seen as coercive, allows any misunderstandings about medication to be identifi ed and corrected, and seems to be more effective in encouraging drug use than direct attempts at persuasion (Coffey 1999). In one exploration of this approach, Kemp et al. (1998) compared motivational interviewing designed to increase adherence to medication with routine care following relapse. The group which received the motivational approach showed higher levels of adherence to the drug regimen and lower readmission rates over an 18-month period. This positive fi nding compares well against even quite sophisticated education programmes involving several sessions, which have not proven so effective.

Minimizing drug usage: early signs

The psychological and physical consequences of long-term drug treatment of schizophrenia have led clinicians to seek innovative methods by which medication usage can be minimized. One approach, involving ‘early signs’, is based on findings that many people with schizophrenia and their families can detect subtle changes in behaviour and mood that precede a relapse (see Box 7.1). The ‘early signs’ approach assumes that while a person is well, they receive less medication or are withdrawn from medication completely. When they experience changes that indicate risk of relapse, these should trigger the individual to seek help (following a prearranged care plan) and to receive intensive drug and/or psychological therapy to prevent relapse and maintain their recovery (Birchwood et al. 2000).

Electroconvulsive therapy

 Electroconvulsive therapy  has been a front-line treatment of schizophrenia in the past, and has achieved some success. A meta-analysis by Tharyan (2002) concluded that  179 7.4 TREATMENT OF SCHIZOPHRENIA about half those treated with ECT showed short-term improvements in general functioning when compared with those given placebo. This effect, however, did not last. Moreover, ECT is less effective than antipsychotic drug treatment. Combining antipsychotic drugs and ECT is of benefit only in the short term, and only one out of every five to six people appears to benefit. For these reasons, ECT in the treatment of schizophrenia has largely been curtailed, and the NICE guidelines for the treatment of schizophrenia did not recommend its use (NICE 2009).

Psychological approaches

Psychoanalytic approaches

One of the first psychosocial treatments of schizophrenia was developed by Harry Stack Sullivan in the early part of the twentieth century. Sullivan (1953) considered schizophrenia to involve diffi culties in living arising from problems in personal and social relationships, and that ‘personality warps’ were the lasting residue of earlier unsatisfactory personal experiences. His treatment approach involved examination of the individual’s life history and the historical roots and current ramifi cations of their maladaptive interpersonal patterns, evident in their relationship with their doctor and in daily life. Characteristic difficulties were thought to include a basic mistrust of others, and a marked ambivalence in relationships, with swings between a longing for, and a terror of, close relationships. Resolution of this conflict through the psychotherapeutic process was thought to result in improvements in psychosis, and maturation of the patient and their non-psychotic personality. While Sullivan’s interventions were important, as they encouraged the psychological treatment of people with schizophrenia, the approach has been found to be less effective than supportive therapy, and is no longer carried out.

Family interventions

The recognition that high NEE was contributing to relapse in schizophrenia resulted in a number of studies of family interventions targeted at its reduction. In one of the earliest of these, Leff and Vaughn (1985) randomly assigned people with schizophrenia who had at least 35 hours per week face-to-face contact with family members in a high NEE household to a family intervention or usual care condition. The intervention included a psycho-educational programme that focused on methods of reducing NEE within the household, family support and the opportunity for family therapy. The programme was highly successful. Nine months after the end of therapy, 8 per cent of the people in the treatment group had relapsed, in contrast to 50 per cent of those in the comparison group. By two-year follow-up, 40 per cent of the treatment group and 78 per cent of the control group had relapsed. A similar therapeutic approach was adopted by Falloon et al. (1982). Their intervention included education about the role of family stress in triggering episodes of schizophrenia and working with the family to develop family problem-solving skills. Their results were equally impressive. At nine-month follow-up, 5 per cent of the people in families receiving treatment had relapsed, in contrast to 44 per cent of those receiving standard medical treatment. By twoyear follow-up, relapse rates were 16 per cent and 83 per cent respectively. On the basis of this and other related evidence, Pharoah et al. (2000) concluded that family interventions reduce risk of relapse by about half in comparison with standard medical care. They also noted that family interventions decreased the frequency of admissions to hospital, time spent in hospital, and improved compliance with medication regimens.

Cognitive behavioural therapy

Two forms of CBT are increasingly being used with people with a diagnosis of schizophrenia. The fi rst, stress management, involves working with individuals to help them cope with the stress leading to or associated with psychotic experiences. The second, known as belief modifi cation, involves attempts to change the nature of delusional beliefs the individual may hold. Stress management Stress management approaches involve a detailed evaluation of the problems and experiences an individual is having, their triggers and consequences, and developing strategies to help cope with them. These include cognitive techniques such as distraction from intrusive thoughts or cognitive challenge, increasing or decreasing social activity as a means of distraction from intrusive thoughts or low mood, and using relaxation techniques. This approach has proven successful in preventing or delaying individuals at high risk of developing schizophrenia moving into a first episode. McGorry et al. (2002), for example, randomized such individuals into what they termed an intervention, involving supportive psychotherapy focusing on social, work or family issues or low-dose risperidone therapy combined with CBT. Each intervention lasted for six months. By the end of treatment, 36 per cent of the people who received supportive psychotherapy progressed to fi rstepisode psychosis compared with 10 per cent in the specific CBT-risperidone group. Short-term gains were also found following a purely cognitive intervention by Morrison et al. (2006), but by three-year follow-up the intervention proved no more successful than usual care. Other studies have evaluated interventions intended to promote recovery following an acute episode of schizophrenia. In one such study, Tarrier et al. (e.g. 2000) randomly assigned individuals to either drug therapy alone, or in combination with stress management or supportive counselling.

The stress management intervention involved 20 sessions in ten weeks, followed by four booster sessions over the following year. By the end of the fi rst phase of treatment, those who received this intervention evidenced a greater improvement than those in the supportive counselling group, while people who received only drug therapy showed a slight deterioration. One-third of the people who received stress management achieved a 50 per cent reduction in psychotic experiences; only 15 per cent of the supportive counselling group achieved this level of benefit: 15 per cent of the stress management group and 7 per cent of the supportive counselling condition were free of all positive symptoms. None of those in the drug therapy group achieved this criterion. One year later, there remained significant differences between the three groups, favouring those in the stress management condition. By two-year follow-up, those who received only drug therapy had significantly more problems than those in the psychological treatment groups. However, both psychological interventions proved equally effective.

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