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Harvard Commentaries
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Reviewed by the Faculty of Harvard Medical School

Minding Your Mind Minding Your Mind

Schizophrenia Treatment: Not by Drugs Alone

November 16, 2013

By Michael Craig Miller M.D.

Harvard Medical School

Schizophrenia is often a devastating psychiatric condition. It is a major cause of disability with huge human and financial costs. In the United States alone, direct costs (medical expenditures, public costs and other related costs) and indirect costs to society and family members have been estimated at more that $60 billion yearly.

Two important features of schizophrenia are psychosis and what psychiatrists call negative symptoms. Psychosis is the inability to recognize reality — for example, delusions (false beliefs) and hallucinations (false perceptions). The negative symptoms of schizophrenia include:

  • A restriction of emotional range
  • A tendency to be inexpressive
  • The inability to be active and productive

These problems almost always result in significant functional decline.

After many years of enthusiasm about new medications to treat psychotic symptoms schizophrenia and other illnesses, recent attention has focused on the limits to their effectiveness and their troubling side effects. But the medications, even if they can often relieve the most dramatic psychotic symptoms, turn out to be just one part of the proper treatment for this disease.

As devastating as schizophrenia is, the problem for the schizophrenia sufferer is compounded by the stigma and public misunderstanding of the illness. As a result, it often takes too long for people to recognize the illness, and good treatment is hard to find even when the diagnosis is made.

Let's look at what experts think these patients with schizophrenia need and why it's so important for them to get that help early on.

Why Is Early Treatment Better?

Early treatment is better, because affected patients respond better to treatment during their first psychotic episode. Also, the greatest decline in functioning is seen within the first few years of making a diagnosis. Symptoms get worse and are harder to treat with each subsequent episode.

Unfortunately, during a psychotic episode, patients may not be aware of the problem and may be too frightened to go for help. If the situation becomes bad enough, they may be forced to go to a hospital. The use of force may frighten them away from getting further treatment. This can lead to a cycle of running away from help, rather than toward it.

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What Does Good Treatment Look Like?

Antipsychotic drugs (for example, newer agents like risperidone, olanzapine, ziprasidone, quetiapine or aripiprazole, and older ones like haloperidol) are the mainstay for reducing psychotic symptoms, and they are most effective during the first psychotic episode. Half of patients have symptom relief within three months and three-quarters are better within six months.

Unfortunately, side effects, such as weight gain or sedation, can be very troubling. Many patients stop taking the drugs. And many people with schizophrenia, even if they continue their medication, remain psychotic. They also are more prone to depression, anxiety and substance abuse. Suicide risk is also higher than average in this population. All of these problems can be dealt with much more effectively if the individual has a close working relationship with a team of professionals.

Because of this complex set of issues, many experts now advocate a specialized system of care designed specifically to deal with the typical problems of schizophrenia. According to the model, teams of mental health professionals in the community reach out to families with intense education and support.

They don't just provide medication. Members of the team help families understand what to expect from medications and respond immediately if uncomfortable side effects occur. They also provide:

  • Timely psychotherapy to assist the person in adapting to the illness
  • Occupational therapy to improve functioning, and
  • Social services to deal with financial support or housing

Crisis centers and hospitalization are available in an emergency.

The first aim is to eliminate psychotic symptoms. At the same time, psychosocial treatment is aimed at helping the person return to better functioning at home, work or school.

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How Effective Is Psychosocial Treatment?

In the last decade, centers in North America and Europe have shown the effectiveness of "multi-element" psychosocial approaches. Patients enrolled in these special programs have seen a reduction in symptoms and fewer hospitalizations than average. Their functioning and quality of life also seem to improve.

It is difficult to perform large controlled studies of these treatments. But there is strong enough evidence to recommend that psychosocial treatment be an integral part of schizophrenia treatment. In fact, that's exactly what an influential set of treatment guidelines recommends.

The Schizophrenia Patient Outcomes Research Team (PORT) was established by the National Institute of Mental Health and the Agency for Health Care Policy in the early 1990s. In 2009, that team updated treatment recommendations for schizophrenia, strongly urging strategies meant to support a patient’s ability to learn to live with the illness.

Many approaches have been shown to be helpful, including:

  • Assertive community treatment – Community-based, multidisciplinary teams have frequent contact with patients to provide practical support.
  • Supported employment — Patients are quickly given appropriate jobs, while also getting training and mental health services.
  • Skills training — Education aims to help patients live independently in the community.
  • Cognitive behavior therapy – In schizophrenia, the aim of treatment is to help patients cope with their symptoms.
  • Alcohol and substance abuse treatment – The focus here is to help patients find ways to cope without turning to substances.
  • Health maintenance – Patients with schizophrenia have a tendency, for example, to be overweight and to smoke cigarettes. They need help to overcome these.
  • Family services – Schizophrenia affects the whole family. Family education and support is an fundamental aspect of treatment.

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Where Is Schizophrenia Treatment Headed?

Resources are limited, so revamping the entire mental health system to provide adequate psychosocial treatment is a formidable task. But current information, and specific recommendations such as those contained in the PORT guidelines, can still help clinicians improve care. After all, the principles that guide specialized schizophrenia treatment teams are the same principles that guide good mental health care for all patients. Medication alone is rarely enough. It makes sense to offer patients a trusting rapport with their clinicians, and an opportunity to discuss their functioning and the quality of their relationships.

Specialized treatment in schizophrenia may be nothing more than a psychosocial approach that takes into account this group's special needs. As research in this are continues, we should learn more about what specific psychosocial interventions are most helpful to people with schizophrenia.

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Michael Craig Miller, M.D., is the editor in chief of the Harvard Mental Health Letter. He is also associate physician at Beth Israel Deaconess Medical Center and assistant professor at Harvard Medical School. He has been practicing psychiatry for over 25 years at Beth Israel Deaconess Medical Center. He teaches in the Harvard Longwood Psychiatry Residency Program.

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