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Harry H Hustig and Peter D Norrie

The heterogeneity of schizophrenia and the stigma attached to severe mental illness make initiating and providing treatment difficult -- but prudent use of antipsychotics, a practical approach to psychosocial treatments and assertive case management can clearly enhance the individual's quality of life.

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Synopsis - Introduction - The nature of schizophrenia - Diagnosis - Medication to reduce symptoms - Managing poor response to treatment - Depression and suicide - Compliance - Alcohol and drug abuse - Psychological intervention - Families - Psychosocial rehabilitation - Authors' details - Box 1: DSM-IV diagnostic criteria for schizophrenia - Box 2: Common side effects of oral antipsychotic drugs - Box 3: Depot medications for schizophrenia available in Australia, November 1997 - Box 4: Psychological therapies in treating schizophrenia - Case history: Timely intervention - Case history: Established schizophrenia resistant to treatment - Short course - Contents list

• There is an increasing expectation that general practitioners will be more involved in treating people with schizophrenia.
  
• Newer drugs are associated with better clinical outcomes, especially in relation to negative symptoms (ie, apathy, underactivity, slowness, social withdrawal).
  
• Some patients make a full recovery or are quite functional between episodes.
  
• Identifying early warning signs will lead to reduction of disability.
  
• Side effects of medication must be treated vigorously and expediently to enhance compliance.
  
• Secondary symptoms of dysphoria and depression must be treated to prevent suicide.
  
• Issues of alcoholism and substance abuse must be addressed, providing education on their implications for the course of the illness.
  
• People with schizophrenia need continuity of care, which the general practitioner may be best placed to provide because of a long-term commitment to the patient.
  
• Involvement with the family (education, support and a collaborative approach in monitoring and supporting the patient's well-being) is vital.

Advances in the understanding of the pathophysiology and pharmacotherapy of schizophrenia, combined with increased community-based rehabilitation, have led to considerable improvements in care. The shift to community-based services, compounded by a shift of psychiatrists away from public to private practice,³ has led to an increased demand on general practitioners. The most expeditious use of resources would be the integrated service model described in chapter 2,⁴ where general practice and mental health services are interwoven to meet patient needs.

An important aspect of the general practitioner's role is in supporting the family of people with schizophrenia. Information about the illness and ways of coping with disturbed behaviour are high priorities for carers, who also express the need for increased contact with doctors.⁵ As access to public sector psychiatrists is diminishing, this task is falling increasingly to general practitioners.

Case history 1:
Timely intervention

The age of onset has prognostic significance: an earlier age of onset, being male, poorer premorbid adjustment, lower educational achievement, more structural brain abnormalities, more prominent negative symptoms and more severe cognitive impairment predict a poorer prognosis.

The course of the illness is quite variable. According to Watt et al.,⁶ 43% of patients have repeated episodes with increasingly severe residual symptoms and no complete remission, 9% have repeated episodes with lasting impairment at a constant level, 32% have several episodes but minimal impairment in between episodes of illness, and 16% have a single episode of the illness with no lasting impairments. The prognosis is more favourable for first-episode patients. There is increasing evidence that psychosis is actively pathogenic or at least that delayed intervention leads to greater secondary morbidity.

Box 3:
Depot medications for schizophrenia available in Australia, November 1997

The acute phase (onset of florid psychosis): The aim is reduction of psychotic symptoms. Start with low doses of a traditional neuroleptic agent (Box 2) or an atypical neuroleptic such as olanzapine (dose, 10 mg daily) or risperidone (dose, 1 mg twice daily, increasing to 2-4 mg twice daily). If sedation is needed an adjunctive benzodiazepine may be of benefit. Referral to a psychiatric service is essential if there is a risk of self-harm or harm to others, and helps to verify the diagnosis and establish collaborative treatment.

Stabilisation phase (the disease resolves or stabilises but the patient is at risk of relapse): The dose of antipsychotic should not be significantly reduced from that used to gain control of the psychosis unless reduction is required to minimise side effects.

The maintenance phase (most of the predominant positive symptoms have resolved): The object is to prevent relapse and reduce the level of disability. Identification of early warning signs may lead to further reduction in maintenance medication.

The choice of drug therapy with traditional agents has been dependent largely upon the side effect profile (Box 2), as the drugs are equally effective in treating positive symptoms (ie, hallucinations, delusions, disturbances in thinking).

The introduction of the safer drugs risperidone and olanzapine has changed drug treatment.⁹ They appear to have equal efficacy, with olanzapine producing fewer extrapyramidal side effects but more weight gain.¹⁰ At low doses such differences may be marginal. Of more importance is the significant reduction in negative symptoms with these agents. Negative symptoms are present at the time of first presentation in 10% of patients. They may be primary, or secondary to depressive symptoms, anxiety symptoms or extrapyramidal symptoms -- specifically, parkinsonism and akinesia.¹¹ Clozapine is not recommended as first line treatment due to the risk of agranulocytosis (incidence, 0.8%-1%), but is the most effective antipsychotic in treatment-resistant schizophrenia¹² and should be used when a person's illness has not responded to at least two different antipsychotics. Clozapine is effective in controlling aggressive behaviour¹³ and associated with a reduction in suicide attempts.¹⁴

Depot medication may enhance compliance, but extrapyramidal side effects are often a problem and compliance with medication to treat side effects remains an issue. At present there are four depot preparations available in Australia (Box 3): the two associated with the fewest extrapyramidal side effects are flupenthixol decanoate and zuclopenthixol decanoate, the latter agent being slightly more sedating and anxiolytic. Zuclopenthixol is also available in short acting form that lasts one to three days and may provide effective sedation in initial treatment.

Case history 2:
Established schizophrenia resistant to treatment

Mood stabilisers such as lithium carbonate, carbamazepine and sodium valproate have shown some benefit in open studies, but their efficacy in treatment-resistant patients remains controversial and monotherapy with an atypical neuroleptic such as olanzapine or risperidone should be attempted first.

The risk of suicide is at least 10%, particularly during the first 10 years of illness. Despite dramatic reports of suicide driven by psychosis, the more common occurrence is suicide during the residual phase of the illness.¹⁶ Those most at risk are the young chronic relapsing patients with good education and high performance backgrounds who show painful insight, feelings of hopelessness and fear of further disintegration, and who have made previous suicidal threats. If suicidal intent is suspected, urgent referral is indicated and the patient may need to be detained.

Although most of the symptoms of depression link more closely with dysphoria than melancholia, antidepressants may be of benefit. In the past, tricyclic antidepressants reduced dysphoria but were often associated with increased side effects, and, given the potential for cardiac arrest in overdose, they were often underprescribed. The newer selective serotoninergic reuptake inhibitors reduce the risks in overdose considerably. They can reduce dysphoria and anxiety, but there may be an increase in agitation and akathisia.

Several factors enhance compliance: details of after-care should be clearly provided to the patient and carer, including specific training in administration of medication; the involvement and contact by the community psychiatric team should be established before discharge; and the clinic milieu should be welcoming and without long waiting periods, as many patients are socially anxious.

Ambivalence about medication is often quite strong. Patients and families need a clear opportunity to ventilate their feelings. The patient needs to be reassured that most nuisance side effects of constipation, dry mouth, blurred vision, dizziness, hypersalivation and sedation will diminish with time, while symptoms such as sexual dysfunction and weight gain tend to plateau.

Extrapyramidal side effects are significantly reduced with antiparkinsonian drugs such as benzhexol, and akathisia responds well to low dose beta-blockers. Simple changes to timing, use of a lower dose or less potent agents and treating specific side effects enhance compliance. It is important that the specific benefits to the individual in taking medication are identified and reinforced.

Dixon reported that 72% of patients with schizophrenia used drugs to get high, an equal number used them to avoid depression and only 15% reported that it was to reduce side effects.¹⁹ Most used illicit drugs to go along with the group. Some patients also admitted that they preferred to see themselves as having a drug problem rather than schizophrenia.

Treatment needs to be individualised, focusing on detoxification, education over the maladaptive effect of drug misuse, the increased risk of schizophrenic relapse and the need to use higher doses of neuroleptics while the abuse is occurring.

Rehabilitation needs to focus on establishing alternative social networks and vigorous treatment of any secondary conditions such as depression or anxiety.

The general practitioner (as in both case examples) is often the only doctor who has known the person before schizophrenia developed. The general practitioner may be aware of the family dynamics and is usually aware of the person's support network. A therapeutic alliance with the patient may already be present. Such a relationship is more difficult to establish in the acute phase or during periods of intense paranoid ideation.

The American Psychiatric Association guidelines in the treatment of schizophrenia emphasise the following components:⁹

• Establishing and maintaining a therapeutic alliance, with continuity of care.

• Monitoring patients' psychiatric states. Collaboration with family members and the support network is essential, as people with schizophrenia often lack insight.

• Education about schizophrenia and its treatment. The patient's ability to understand and retain information fluctuates. Education should be ongoing and lead to a collaborative approach and must be extended to family members.

• Establishing an overall treatment plan. This is an iterative process, depending on patient response and preferences, and collaboration with specialist psychiatric services.

• Enhancing adherence to the treatment plan. This requires the acceptance of psychosocial intervention, vocational goals and addressing relationship issues. An atmosphere of tolerance in which patients feel free to discuss treatment critically improves collaboration and reduces drop-outs.

• Increased understanding of effect of the disability, by assisting patients to cope with their interpersonal relationships, work, and other physical health needs (e.g., helping them determine who they can share their delusional beliefs with). Assistance and coaching with basic problem-solving skills is often of great benefit.

• Identifying stressors and early warning signs that could initiate relapse. Early warning signs are often non-specific and may just present as a change in mood, anxiety or social withdrawal. They are often consistent in subsequent episodes and often initially detected by family members two to four weeks before relapse.¹⁸

• Reducing family distress and improving family functioning.

• Facilitating access to services (mental health, general medical and welfare). The general practitioner, treating psychiatrist and mental health team need to work collaboratively in arranging such things as disability income support, housing and other services for which patients or their families are unable to advocate effectively.

There is often considerable family guilt and shame, which can be reduced by focusing on the biological causes of schizophrenia. Symptoms need to be clearly explained, particularly negative symptoms, which are often misinterpreted as laziness. Realistic information about prognosis is essential. Information about the different types of treatment and relative risks and merits, including the availability of community-based services and utility of hospitalisation, is essential. The family will also need help in coming to terms with the loss of aspirations that they had for the patient.

Reducing face-to-face contact between family and patient often helps reduce tension. As most patients with significant disability are unable to obtain open employment, day programs, self-help groups and leisure activities that take the patient out of the house are all useful alternatives.

Overinvolvement often occurs during the early phase, usually during the patient's adolescence. If brief trials of separation are to be successful then the mirroring between the patient's dependence and the relatives' anxiety needs to be addressed. The parents' focus often needs to be redirected to the marital relationship, which has often been neglected in an excessive focus on the patient. The patient needs to seek peer contacts outside the home.

Box 4:
Psychological therapies in treating schizophrenia

However, support, understanding, encouragement, explanation, advocacy, the maintenance of the person's physical health, and an integrated collaborative approach with specialist services are the tools of rehabilitation that will enhance patient outcome and quality of life.

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