HOW TO TREAT 41 severe constipation ( up to 60 %) and seizures at high doses . In addition , there are significant difficulties with weight gain , sedation , fatigue , tachycardia , hypersalivation , postural hypotension and nocturnal enuresis . This long and complex list of adverse effects needs close medical supervision .
Psychosocial treatment
In addition to pharmaceutical treatment , a comprehensive psychological and social response is needed for the individual and their family . Schizophrenia is a very confronting illness ; it is very difficult to deal with on an individual level and is associated with disorganisation , amotivation and a considerable loss of function . It is challenging for the family because of the change it causes in many aspects of the person ’ s nature , their life trajectory and the severe stigma associated with the diagnosis .
Improvement in acute symptomatology can often be seen in weeks . However , the recovery of the individual in a holistic way — involving symptomatic improvement , a return to function , social engagement and personal understanding — usually takes years . To achieve this will require a range of health professionals and peer involvement . Unfortunately , there is only patchy availability of appropriate services to achieve this ; however , the introduction of the NDIS will allow a small number of the most impaired to access better services . Avenues for psychosocial interventions will increase with the existence of the NDIS as a source of funding .
Services to consider
The first few years after the diagnosis can be a time of relapse and readmission to hospital . Integration of care with a community mental health team , sometimes a specialised early psychosis or youth mental health team and a case manager , can be very useful during this time . Assertive follow-up and co-ordination of care by a case manager can be of great assistance , with the case manager also being the access point for other psychosocial care . As part of this care , providing basic information about the diagnosis and treatments to both the individual with the illness and their family is essential .
The psychological treatment of psychotic symptoms , depression or anxiety can be done by a clinical psychologist , using cognitive behavioural therapy . This may require a mental health care plan or be provided by the specialist community mental health team . In addition to these specific interventions , support for the patient coming to terms with the diagnosis of schizophrenia may be required . This supportive intervention is certainly within the skill set of most GPs .
The cognitive deficits seen with schizophrenia can be helped using cognitive remediation techniques aimed at both the neurocognitive ( attention ,
How to Treat Quiz . concentration , memory , planning skills and speed of processing ) and social cognitive ( emotion recognition , theory of mind and social knowledge ) deficits . Schizophrenia can cause a loss of social and functional skills . Assessment is best done by an occupational therapist familiar with the area ; implement interventions aimed at improving the person ’ s ability to perform their activities of daily living and other interactive social skills .
Trials that have combined cognitive remediation with other psychosocial interventions have found a synergistic effect . 28 Unemployment is a significant issue for many people with a psychiatric diagnosis but especially for people with schizophrenia . Involvement with a supported employment program , especially one that provides individual placement and support , improves the likelihood of a successful return to work . 29 Again , this is improved by combining with other psychosocial programs .
Treatment of medical comorbidity
An essential role for the GP in the care of a person with schizophrenia is the monitoring and assertive treatment of physical illness . There is a substantial gap of around 13-15 years of potential life lost for people with schizophrenia when compared with the general population . 30 This gap is because of an increase in cardiovascular disease , not suicide . 31 Worryingly , there is good
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1 . Which THREE statements regarding schizophrenia are correct ? a The disorder can be understood as the result of a genetic vulnerability interacting with developmental stressors . b The genes predisposing to schizophrenia overlap with those associated with a range of other psychiatric disorders . c A single gene defect is necessary for development of the disorder . d The implicated environmental factors include prenatal , perinatal and early and later life stressors .
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2 . Which ONE statement regarding the epidemiology of schizophrenia is correct ? a The disorder is more common in women than in men in Australia . b Most people with schizophrenia are homeless . c The age of onset of a psychotic illness is under 25 with the first symptoms evident in the teenage years . d Almost half of those with schizophrenia work in sheltered employment .
3 . The signs and symptoms of schizophrenia can be grouped into which THREE domains ? a Disorganisation . b Loss of insight . c Positive . d Cognitive .
4 . Which TWO statements regarding the signs and symptoms of schizophrenia are correct ? a Positive symptoms dominate during periods of acute illness and early in the course of the illness . b Cognitive deficits respond to antipsychotic medication . c Negative symptoms refer to the loss of capacity to express emotion , think , engage socially or participate in a motivated and goal directed way . d Auditory hallucinations are pathognomonic for schizophrenia .
5 . Which THREE statements regarding the investigation of schizophrenia are correct ? a HIV or syphilis serology is indicated for all people with their first episode of psychosis . b Investigations will identify brain disorders masquerading as schizophrenia and establish a baseline for the physical health issues . c Brain imaging is appropriate for the initial workup of someone with their first episode of psychosis . d Symptoms are required to persist for at least six months to justify the diagnosis of schizophrenia .
6 . Which TWO statements regarding the management of schizophrenia are correct ? a LAIs do not decrease the rates of relapse . b Clozapine is the most effective of the antipsychotic medications for the treatment of schizophrenia . c Poor treatment adherence or continued substance use may result in a poor response to an antipsychotic medication . d Benzodiazepines are not recommended in combination with antipsychotic medications .
7 . Which THREE medications are first line in the treatment of schizophrenia ? a Risperidone . b Amisulpride . c Olanzapine . d Aripiprazole .
8 . Which THREE statements regarding the treatment of schizophrenia are correct ?
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SCHIZOPHRENIA
evidence that people with schizophrenia receive poorer quality clinical care for their physical illnesses , and are less likely to receive guideline indicated medication or interventions in comparison with people from the general community for both cardiovascular
32 , 33 disease and cancer .
People with schizophrenia not only have lower rates of intervention for their physical health problems but also high rates of smoking , substance abuse , poor nutrition , obesity and low rates of exercise . 1 The heart of the matter is to move beyond screening and recognition into intervention for physical illness as would be indicated for anyone else in the community . Treatments for cardiovascular disease , the early recognition of hyperglycaemia , smoking cessation , nutritional advice and exercise are effective in people with schizophrenia , although depression and negative symptoms are additional barriers to their implementation . 34-36
Although antipsychotic medication can increase appetite and worsen peripheral insulin sensitivity ( particularly olanzapine , quetiapine and clozapine ) contributing to weight gain and hyperglycaemia , remaining on antipsychotic medication is associated with a decrease in overall mortality compared with being unmedicated . 37 This is likely a result of the beneficial effects of treatment on mental health , stability of engagement with the community and the continued interaction with health professionals .
a Integration of care with a community mental health team and a case manager , can be very useful . b CBT may be used for psychotic symptoms , depression or anxiety . c There is little benefit in combining psychosocial interventions . d Involvement with a supported employment program improves the likelihood of a successful return to work .
9 . Which ONE is the most common cause of premature death in those with schizophrenia ? a Suicide . b Cardiovascular disease . c Lung cancer . d Unintentional drug overdose .
10 . Which TWO statements regarding the prognosis in schizophrenia are correct ? a Full function and symptomatic recovery occur in 8-20 % of patients . b A trial of clonazepam is essential for those with frequent relapse , requiring higher doses of medication and poorer outcome . c The outcomes in schizophrenia are highly predictable . d Many patients have a pattern of relapse and chronicity , with negative symptoms and poor social functioning .
PROGNOSIS
IN the same way that schizophrenia is a highly protean disorder on clinical presentation , so it is with outcomes . Full function and symptomatic recovery is seen , but it is rare , with as few as 8-20 % achieving this . 38 On the other hand , improved recovery rates ( 30 %) in more recent studies of first episode schizophrenia have been seen , suggesting that recent changes of practice may have helped . 39 However , for most , further relapse and an evolving pattern of chronicity , negative symptoms and poor social functioning is common . If this latter pattern of illness is established , such that the individual has relapsed and required both higher doses of medication and achieved a poorer outcome , then continued antipsychotic medication is recommended . A trial of clozapine is essential for this group of patients with schizophrenia .
THE FUTURE
WHILE no breakthroughs have occurred , real progress has been made in the understanding of schizophrenia with confirmation of the polygenetic origin of the disorder and the role of autoimmune mechanisms for a small number of people with psychosis . This has not been translated into radically improved treatments , rather there has been an incremental change in the range of treatments , both pharmacological and psychosocial . The introduction of the NDIS should improve access to psychosocial treatments in the community , however the rollout has been slow for people with a severe mental illness and the availability of skilled therapists remains limited .
CONCLUSION
SCHIZOPHRENIA remains a scourge . It strikes early in adult life , disabling most people who are afflicted , isolating them from others and impeding their ability to work and play . Finally , it contributes to their early death . Management requires a multidisciplinary team , with the GP playing an essential role .
Recent additions to the pharmacological treatment of schizophrenia have not significantly changed treatment outcomes but have provided a greater flexibility in choice . Psychosocial interventions are potentially more available and are an important and neglected component of management . Improvement in outcomes await change in our basic knowledge of the aetiology of the disorder and the translation of this knowledge into more effective treatments — physical , pharmacological and psychosocial .
Disclosure notice Dr Harris has received consultancy fees from Janssen Australia , Lundbeck Australia and Seqirus . He has received payments for educational sessions run for Janssen Australia , Lundbeck Australia and Servier . He has developed educational material for Servier . He is the recipient of an investigator initiated grant from the Balnaves Foundation and Takeda Pharmaceutical Company . He is an investigator on an industry sponsored trial by Alto Neuroscience . He is the recipient of funding from the Australian Research Council , the Medical Research Future Fund and the National Health and Medical Research Council . He is the chair of One Door Mental Health .
References Available on request from howtotreat @ adg . com . au