Volume 178 · Issue 9 · Supplement

In Australia there continue to be significant barriers to care and gaps in service provision for people with schizophrenia. The extent of these shortcomings is echoed in the National Survey of Mental Health and Wellbeing study on low-prevalence (psychotic) disorders.1 Of the 998 people with psychotic disorders surveyed, 84% were single, separated, divorced or widowed; 85% were reliant on welfare benefits; 72% did not have a regular occupation; and 45% were living in some form of hostel or supported accommodation, or were homeless. These unacceptable psychosocial outcomes were evident despite the fact that 91% of the people surveyed were currently receiving psychotropic medication. Furthermore, only 19% of patients had used any form of rehabilitation service over the previous year. It was not that they did not want to access such services; indeed, 47% of the survey cohort perceived the need for a particular type of service that was not accessible to them, either because it was unavailable or they could not afford it. The service provider with whom the majority of survey respondents did have regular contact was their general practioner: 81% had seen their GP in the previous year, and the average number of visits was 12 per year.1 Clearly, not all of these contacts were for mental health reasons, but the extent and regularity of contact with GPs by people with schizophrenia highlights the potentially crucial role GPs can play in their overall health. GPs are likely to have increasing involvement with managing medical comorbidity in patients with schizophrenia, especially now that newer "atypical" antipsychotic drugs are available. Thus, this Supplement, highlighting the latest developments in managing schizophrenia and delivering comprehensive care, is particularly relevant for GPs. Hocking (page 47)2 underlines the place of the community in schizophrenia management — highly pertinent in these "post-institutionalisation" days, when the vast majority of people with schizophrenia are resident in the community. It is important that GPs understand the functioning of the modern mental healthcare system, know what resources are available to assist in managing patients with schizophrenia, and have the information required to negotiate potential barriers to accessing support services. These issues are detailed by Harvey and Fielding (page 49).3 A model for GP participation in managing people with schizophrenia is outlined by Meadows (page 53),4 in the hope that the principles can be adapted more broadly. There have been substantial recent developments in pharmacological treatments for schizophrenia. No longer are treatments for psychosis inevitably associated with unpleasant and potentially debilitating extrapyramidal side effects such as parkinsonism, akathisia and tardive dyskinesia. The newer "atypical" antipsychotics are much less likely to have these disabling side effects, and are now first-line treatment for schizophrenia. However, the atypicals have been associated with other medical problems, including weight gain,5 diabetes6 and hyperlipidaemia.7 The decision about which drug to use for any individual patient requires a careful weighing of the side effects against potential therapeutic effects. An overview of the atypical antipsychotics is provided by Lambert and Castle (page 57).8 Despite pharmacological advances, some patients remain "resistant" to conventional treatments. However, we are increasingly able to offer such patients newer treatments that more effectively reduce psychotic symptoms and enhance quality of life. Indeed, the newer agents can have benefits in a number of domains, including those of behaviour, depressive and suicidal thoughts, and cognitive functioning, as well as improving social and vocational outcomes. The management of "treatment resistance" in schizophrenia is reviewed by Pantelis and Lambert (page 62).9 The physical health of people with schizophrenia is often suboptimal, and general medical conditions may either be missed, through inadequate screening, or treated suboptimally. The GP has a crucial role to play here. Lambert et al (page 67)10 outline the main medical problems encountered in people with schizophrenia and the barriers to detection and treatment. Many of the interventions for general medical conditions such as obesity and hypertension require educating the patient about "healthy living", including regular exercise, attention to diet, and stopping smoking. A common problem among people with schizophrenia is the misuse of alcohol and illicit substances. Substance misuse impairs the overall health of the individual, resulting in more severe symptoms, greater chance of relapse and re-hospitalisation and, in some instances, increased risk of crime and violence. Again, the GP has an important role to play in detection and management of comorbid substance misuse. Lubman and Sundram (page 71)11 provide practical guidance for GPs in dealing with this complex issue. Finally, Crosse (page 76)12 suggests ways in which people with schizophrenia can be helped to participate fully in society so that each day is full and meaningful. This should be the aim of all of us involved in the care of people with schizophrenia.

David J Castle MD, MRCPsych, FRANZCP · Christos Pantelis MRCPsych, FRANZCP

The stigma associated with schizophrenia is pervasive, both in the community and among healthcare workers, and forms a real barrier to optimal recovery from the illness. The negative consequences of stigma include discrimination in housing, education and employment, and increased feelings of hopelessness in people with schizophrenia. Health professionals have a responsibility to improve their own attitudes and behaviour towards people with schizophrenia so they do not contribute to the stigma. Educational campaigns aimed at people in the community and media personnel could help to demystify mental illness and reduce the portrayal of offensive stereotypes of people with schizophrenia.

Barbara Hocking BSc(Hons), DipEd, DipHEd, GAICD

In Australia, the configuration of public mental health services varies between States and Territories, but, overall, community-based services are increasingly integrated and responsive to people with schizophrenia. Community-based services include mobile crisis teams, providing home-based acute treatment, and case-management services for ongoing treatment. Service improvements have been uneven across Australia. Some people with schizophrenia in psychiatric crisis have had difficulty accessing either home-based acute psychiatric treatment or acute psychiatric beds. Social isolation and lack of meaningful occupation continue to be a problem for people with schizophrenia. Psychosocial interventions can enhance reintegration into the community. However, the number of community-based psychosocial rehabilitation programs is still inadequate.

Carol A Harvey MRCPsych, FRANZCP · John M Fielding MD, FRANZCP

Many people with schizophrenia are in regular contact with their general practitioners. GPs commonly play a sentinel role in management, but may require support from Area Mental Health Services (AMHSs). The CLIPP (Consultation and Liaison in Primary-care Psychiatry) shared-care model of patient management combines a collocated consultation/liaison service for managing referrals from GPs to specialists with a carefully structured approach to long-term care of patients transferred from AMHS care to GPs. The CLIPP model uses the concept of a "relapse signature", involving recognition of early warning signs of relapse, to simplify clinical monitoring of patients with schizophrenia.

Graham N Meadows MBChB, MRCP, FRANZCP

Pharmacological treatment remains the mainstay of the management of schizophrenia. Older, "typical" antipsychotics carry a significant burden of side effects, notably extrapyramidal and neurocognitive side effects. Newer, "atypical" agents carry a lower risk of extrapyramidal side effects. They appear to have added benefit for treating negative and cognitive symptoms of schizophrenia, and hence can enhance the quality of life of some patients. The choice of particular agents for individual patients requires a balancing of efficacy and side effects. Medication is only one element of what should be an individualised comprehensive treatment plan for people with schizophrenia.

Timothy J R Lambert BSc, MB BS, FRANZCP · David J Castle MD, MRCPsych, FRANZCP

Patients who fail to respond adequately to pharmacological treatment present an ongoing therapeutic challenge. The term "incomplete recovery" (IR) is preferred to the current term "treatment resistance" to describe these patients. IR should be considered from a multidimensional perspective that includes a broad range of symptoms and functional disabilities that are relevant to schizophrenia. The approach to the incompletely recovered patient needs to be systematic, with consideration given to the factors that may hamper recovery. "Atypical" (second-generation) antipsychotic drugs target various domains of symptoms relevant to IR. Adjunctive treatment strategies (eg, mood stabilisers, antidepressants, combinations of antipsychotics) may be useful, but should be undertaken in specialist psychiatric settings. Although pharmacological treatment is a necessary first step in managing incompletely recovered patients, adjunctive psychosocial interventions are needed to optimise treatment success.

Christos Pantelis MB BS, MRCPsych, FRANZCP · Timothy J R Lambert BSc, MB BS, FRANZCP

Schizophrenia has been described as a "life-shortening disease", and physical comorbidity accounts for 60% of premature deaths not related to suicide. People with schizophrenia and other mental illnesses have a higher rate of preventable risk factors such as smoking, high alcohol consumption, poor diet, and lack of exercise. Recognition and management of morbidity in people with mental illness are made more difficult by barriers related to the patient, the illness, the attitudes of medical practitioners, and the structure of healthcare delivery services. Improved detection and treatment of medical illness in people with schizophrenia will have significant benefits for their psychosocial functioning and overall quality of life.

Timothy J R Lambert BSc, MB BS, FRANZCP · Dennis Velakoulis MB BS, FRANZCP · Christos Pantelis MB BS, MRCPsych, FRANZCP

Smoking presents a substantial health and economic burden to people with schizophrenia. Comorbid use of other substances is common, under-recognised, and associated with a number of serious adverse consequences, such as psychotic relapse and poorer social outcomes. All patients with schizophrenia need to be screened for substance misuse. Effective interventions involve integrated, modified pharmacological and psychosocial strategies.

Dan I Lubman PhD, FRANZCP, FAChAM · Suresh Sundram PhD, FRANZCP

While many of the overt symptoms of schizophrenia may be controlled by medication, the associated psychiatric disability requires ongoing psychosocial rehabilitation and support in the community. The general practitioner can play a crucial role in this rehabilitative process, through

Caroline Crosse BA (Hons)