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Psychiatry texts suitable for assisting GPs in treating schizophrenic patients^9,10 do not provide comprehensive practical guidelines for primary care. The two papers* in this series are intended to help fill this gap until specific primary care research provides more knowledge.

Treatment for schizophrenia is multimodal: antipsychotic medication and learned palliative coping techniques act on the underlying vulnerability; social support and instrumental coping (coping behaviours in relation to external rather than internal or disease-related events) help in adaptation to potentially stressful life events; and family interventions and rehabilitation strategies can augment protective factors or counter perpetuating influences.

Schizophrenic patients often have other, traditionally non-schizophrenic, symptoms such as depression, anxiety, somatisation, phobias, obsessions, compulsions, and post-traumatic stress symptoms.

There are two main facets to early detection:
• identifying individuals with prodromal symptoms before the emergence of frank psychosis; and
• recognising early or incipient psychotic symptoms.^18,19

Prodromal assessment: Schizophrenia cannot be diagnosed on the basis of prodromal symptoms alone because these are non-specific.^20,21 They include impaired concentration, anxiety, depression, irritability, rebelliousness, social withdrawal, loss of interest or motivation, impaired function at school or work, deteriorating self-care, somatic complaints, restlessness, self-injury or suicide attempts, alcohol and drug abuse, emotional lability, and uncharacteristic aggression or poor impulse control. Also, it is important to note that the odd ideas or perceptions and peculiarities of speech or behaviour occurring in the prodromal stages of schizophrenia may also occur in normal adolescents.²¹ In schizophrenia, such phenomena may be present for two years or more, although usually not longer than 6-12 months, before the onset of psychotic symptoms.^15,22 If such non-specific problems occur in an adolescent or young adult, they should be taken seriously, the possibility of schizophrenia kept in reasonable perspective, and the patient referred for psychiatric assessment with a letter detailing the main findings.

While such an assessment in the prodromal phase may be inconclusive, it can be useful because, firstly, a positive encounter with a psychiatrist or mental health team establishes an important contact that can be resumed in the future. Secondly, the GP can provide ongoing support to the patient and family while diagnostic uncertainty prevails by acknowledging the problems identified and helping to implement any recommendations made by specialist services. Dismissing the problem ignores and invalidates the family's experience and may foster denial and thereby delay reassessment and hence eventual diagnosis and treatment. Thus, a useful short term measure may be a supportive counselling approach incorporating simple problem-solving strategies. Thirdly, it is important to monitor progress carefully in repeated clinical assessments, enlisting the cooperation of both patient and family, so that significant clinical change can be detected swiftly.

Early psychotic symptoms: GPs are generally better able to detect psychiatric problems if they have good rapport with their patients, an interest in psychosocial problems, the ability to convey interest and concern, and good interviewing skills.^23-25 The latter include appropriate eye contact, empathic responsiveness to cues of emotional distress, attentive posture, listening with few interruptions, an unhurried style, and the capacity to ask directive questions of a psychosocial nature. If indicated, GPs should ask, matter-of-factly and without embarrassment, a set of questions designed to elicit psychotic phenomena. For example:

Do you hear noises or voices when there is no-one speaking or nothing to explain what you are hearing? What do they say? How many are there? Do they seem to be having a conversation among themselves about you?; or

Do you have experiences that no-one else thinks are true, such as feeling you are under the control of some person or force that you can't explain, believing that the radio or TV are referring to you, thinking that others can read your mind, suspecting that someone is trying to hurt you?; or

Is there some interference with your thinking such as thoughts being put into your head which are not your own, feeling that your thoughts are broadcast aloud so that other people can hear what you are thinking, feeling that thoughts are being taken out of your head against your will?.

Patients experiencing their first early psychotic symptoms may deny or conceal such experiences. However, if asked these questions in the context of a confiding relationship, they may be able to acknowledge them for the first time. More harm is probably done if such symptoms persist undetected and untreated than would occur by asking about them in their absence.

Having detected a possible new case of schizophrenia, referral to a psychiatrist or mental health service is imperative. While prolonged delays in the referral process are unacceptable, time should be taken to discuss the reasons for and purpose of the referral with the patient and efforts made to identify a psychiatrist or clinical service team suitable for the individual concerned.

For all these reasons, GPs should remain wary of a diagnosis of schizophrenia, even when long "established". If response to treatment is poor or the patient seems particularly sensitive to the adverse effects of treatment, a reappraisal of the diagnosis, including specialist reassessment, should be considered.

If there is no well developed relationship between patient and GP before the onset of psychosis, one can be developed during the several 10-15-minute consultations per year which these patients tend to have with their GPs for renewal of prescriptions and other medical matters;^6,32 the interview skills referred to previously are required. A trusting atmosphere can thus develop and be used as a basis for supportive therapy. Patients should be treated as autonomous adults, capable of mature decision-making and able to adopt a rational approach to the illness and its treatment. Fostering a collaborative partnership between patient and doctor for the joint management of the illness helps to counter the low self-esteem and lack of confidence that usually follows the experience of psychosis.

Management protocols for common problems in treating schizophrenia can be developed based on the case register. For example, missed appointments by schizophrenic patients are likely to portend relapse, deterioration in functioning, depression, suicidal preoccupations or an episode of drug or alcohol abuse. The management protocol could include having receptionist staff first notify the GP of a missed appointment, followed by telephone contact, home visit, or notifying the patient's community mental health team. It would also serve the patient's interests if the management protocol had the flexibility to handle unscheduled appointments -- frontal lobe impairments can make it difficult for schizophrenic patients to plan ahead or to appreciate the need to make appointments, and they may simply turn up unexpectedly. Also, in group practices, one GP should be identified as the primary care provider for a particular patient to facilitate the personal continuity of care. A standard record-keeping format with a checklist of items individually tailored for each patient may help to ensure that important clinical matters are not overlooked.

If there is no immediate danger, the GP should approach the patient in a calm, non-threatening manner, avoiding confrontation, and conduct an interview in a safe place with whatever privacy is feasible, but with adequate assistance at hand.³³ This can be provided by ambulance officers, medical or paramedical personnel and other responsible individuals.

In either case, having interviewed the patient long enough to confirm, using whatever additional information is available from others, that the patient's condition meets the criteria for involuntary admission, then the GP should arrange that promptly according to the relevant mental health act. The patient should be informed of this and the legal status of the order explained simply and directly. Patients should be taken to hospital by ambulance (rather than police car) under appropriate supervision; this is both safer for patients, especially if sedated, and also underlines the medical nature of the problem. Police officers should accompany the patient in the ambulance if continued restraint is necessary. Transport by police vehicle should be avoided as it is invariably traumatising for the patient and conveys an entirely wrong message to the patient as to the nature of the situation.

Sedating an involuntary patient in the community before transport to the hospital should be avoided if possible, as it may interfere with subsequent diagnostic assessment. However, sedation is clinically indicated (although the legality varies from State to State) for patients thought to be at high immediate risk of injuring themselves or others, who require restraint to enable transportation, or if transportation is likely to be of long duration.³⁴ The patient may need to be restrained first or, alternatively, may accept medication on being confronted by the persuasive presence of enough people.

Sedation can often be achieved by giving chlorpromazine (100 mg) or diazepam (10-20 mg) orally; severely agitated psychotic patients may require diazepam (10-20 mg, orally) together with haloperidol (5-10 mg, orally). Suitable parenteral medications include intramuscular injection of droperidol or haloperidol (5-10 mg) and/or midazolam (2.5-5 mg).³⁴ If a high potency antipsychotic drug is administered parenterally, it should be accompanied by benztropine (2 mg, intramuscularly) to avoid serious acute dystonic reactions like laryngeal dystonia. Intramuscular injection of chlorpromazine is always contraindicated as it can cause an injection abscess, while that of diazepam is unsuitable because rates of absorption vary.

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Reprints: Professor V J Carr, Discipline of Psychiatry, Faculty of Medicine and Health Sciences, The University of Newcastle, Callaghan, NSW 2308.

©MJA 1999

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