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Schizophrenia today
Improvements in treatment need to be built upon and applied more widely and effectively
MJA 2000; 172: 470-471
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Schizophrenia Awareness Week (21-27 May) has been running in
Australia since 1981. During the past 19 years some of the original
goals of the week have been achieved largely thanks to the efforts of
the State-based Schizophrenia Fellowships and the mental health
advocacy and education organisation SANE Australia. These goals
have included getting the word "schizophrenia" into the public
domain, educating the community about the treatability of the
disorder, and encouraging groups of carers to work together to
provide mutual support and to lobby governments for enhanced
services for people suffering from psychotic disorders.
Today, treatment is much more likely to occur in the community, allowing patients to retain a much-valued independence (although loneliness and ennui often develop in the absence of appropriate social supports). Today, medication options are also wider, with clozapine having been used by nearly 10 000 Australians with treatment-resistant disorders (Clozaril Patient Monitoring System, Mental Health Research Institute, Melbourne, unpublished data), and other dopamine and serotonin antagonist drugs, such as risperidone and olanzapine, finding an important role because of their fewer extrapyramidal side effects and, probably, better neurocognitive outcomes.1,2 Our understanding of the biology of schizophrenia has progressed, despite the absence of a signature pathophysiology. This understanding has evolved in light of growing evidence that the disorder is associated with disturbances of neural connectivity and neurodevelopment, and abnormalities in dopaminergic, serotonergic, GABAergic and glutamatergic neurotransmission, involving particular brain regions, including the hippocampus, ventral striatum, and prefrontal cortex.3,4 Nonetheless, schizophrenia remains one of the most stigmatised of all disorders. That the term often conjures up sentiments of derision rather than compassion is well illustrated by a recent description of the Federal Government's actions towards certain UN committees as ". . . at times, sycophantic, abusive, schizophrenic and downright childish".5 The extensive and enduring impact of schizophrenia and related psychiatric disorders on the lives of affected Australians has been brought into sharp focus by a recent Commonwealth Government-sponsored National Survey of 980 individuals with psychotic disorders, more than 60% of whom had schizophrenia.6 It found that the average duration of symptoms was 15 years; 47% of participants were judged to be seriously impaired, 58% were socially withdrawn and 72% did not have a regular job. In addition, the prevalence of tobacco use (males 73%, females 56%), alcohol misuse or dependence (30%), and dependence on or misuse of street drugs (cannabis 25%; others, including heroin, 13%) was considerably higher than in the general population. However, a significant minority of patients -- approximately 25% -- have only one or two episodes of illness, do not continue to need mental health services, and have lower levels of symptoms, impairment and disability. Other data indicate that the rate of suicide among people with schizophrenia is approximately 10 times higher than that in the general population.7 One troubling response to data such as these has been a call -- based on a prediction that Australian mental health budgets are likely to remain relatively fixed -- for reduced emphasis on the treatment of psychotic disorders because of their chronicity and perceived intractability, and for transfer of resources to disorders such as anxiety and depression, which are associated with better responses to treatment.8 An alternative, and in our view far preferable, response is to concentrate on strategies which use what data we have to press for greater overall funding for mental health. There is a strong case for this, as mental illnesses account for 13% of Australia's health burden, third in importance after heart disease and cancer.9 Further, there are several sources of optimism that such strategies will be successful and that new funding is obtainable. For example, prior to 1993, mental health was almost exclusively the preserve of the States and Territories, with the Commonwealth contributing only to Medicare and pharmaceutical benefits. However, since the First National Mental Health Plan, in 1993, the Commonwealth Government has become a significant contributor to public sector psychiatric programs, allocating more than $595 million to them over the years 1993-2003. Also, the States and Territories increased their funding by more than 14% in real terms between the 1992/93 and 1996/97 financial years.10 Another cause for optimism is that, even with high-disability disorders like schizophrenia, there are many measures that meaningfully improve the quality of life of affected individuals, but which need to be better applied. These include early intervention,11 community-based rehabilitation programs, family psychoeducational programs, a greater but targeted use of the newer antipsychotic drugs,12 and good access to residential disability support services and public housing. General practitioners, especially those able to work in conjunction with specialist mental health teams, are in a position to play key roles in ensuring that their patients are offered such treatments and services. This is because people with psychotic disorders often attend GPs (eg, more than 80% had attended their GP in the 12 months before being interviewed in the National Survey,6 with a median of five attendances during that time). The Consultation Liaison in Primary Care Practice (CLIPP) Program13 is one of a number of successful models of collaboration between GPs and mental health services that provide substantial benefit to patients. Future improvements in the management of schizophrenia will require better communication and coordination between patients and carers, medical practitioners, mental health services, and non-government agencies. It will also require the development of new services, the refinement and strengthening of existing ones, especially in the psychosocial domain, the discovery of prognostic markers, and the introduction of novel pharmacotherapies. Fundamental and applied research will be essential to the successful achievement of many of these outcomes. David L Copolov Bruce S Singh
©MJA 2000
Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 2000 Medical Journal of Australia. We appreciate your comments. |