Treatment of schizophrenia

• Introduction

• Drug therapies for psychotic symptoms: typical, atypical antipsychotics

• Talking therapies and support

• Alternative therapies

• Future

• Find out more

• References

Introduction

Treatment for people with schizophrenia almost always involves drug therapy. It aims to stabilize psychotic symptoms and reduce their chances of relapse. It also aims to improve their ability to resume everyday life and to live independently.

Drugs can relieve some symptoms for some people, but there is a need for better-tolerated, more effective drugs. Psychotherapies have proved useful in schizophrenia but may not always be available on the NHS.

Treatment for schizophrenia can be controversial. There are currently two related areas of controversy in the UK - the cost of medication and its side effects. Roughly one third of people with schizophrenia do not take their medication; unpleasant side effects of antipsychotic drugs are a major reason for this.

Schizophrenia is an expensive illness. Only 1% of the population will have schizophrenia at some point during their lifetimes, but the condition accounts for 2.5% of total healthcare costs in the UK. Much of this expense comes from hospitalisations and caring for people with schizophrenia who do not respond well to treatment. The drugs themselves only account for about 10% of total spending on schizophrenia. ¹

"If you are lucky enough, like me, to have no response to your first antipsychotics, you can be put on an expensive drug called Clozaril. This drug costs £6,000 per year. However, it costs £1,000 per week to keep a person with a mental illness in hospital." Claire, service user

This section covers the available treatments for schizophrenia and considers future approaches to the condition.

Drug therapies for psychotic symptoms

The drugs used for schizophrenia are collectively called antipsychotics or neuroleptics (they used to be called major tranquillizers). Antipsychotics are divided into groups according to their chemistry and pharmacology (see Table 1). The two major groups are typical and atypical antipsychotics based on their side effects.

Antipsychotic drugs can take between one and three months to take effect.

Typical antipsychotics

The typical antipsychotics include haloperidol, chlorpromazine, chlorpromazine and thioridazine. Most are given as tablets or syrup. Some (e.g. zuclopenthixol, flupenthixol) are available as long-lasting (two-six weeks) 'depot' injections.

Depot antipsychotics mean that tablets do not have to be taken every day, but like any medication, they have side effects, which can be severe. The depot injection can also cause blistering and skin irritation at the point of injection (usually a buttock).

Typical antipsychotic side effects

Antipsychotics can have a range of side effects. These are listed in the section on atypical antipsychotics. Specific side effects of typical antipsychotics are severe movement disorders, called extrapyramidal side effects. These usually affect about one person in three and include:

• Muscle spasms - often in the head and neck after a first dose or a change in dose; may be accompanied by rolling of eyeballs
• Unusual body movements - medium to long-term (pseudoparkinsonism). Involuntary movement disorders such as limb rigidity and tremor, similar to the symptoms of Parkinson's disease.
• Severe movement disorders - called tardive dyskinesia. It consists of unusual and repetitive movements of the face, tongue and neck muscles and sometimes of the arms and legs. Tardive dyskinesia develops in people who have been on typical antipsychotics for three months or more, or when people come off them. In people aged 60 or more, it can happen after only one month. It is usually irreversible, even when antipsychotics are stopped.

Extrapyramidal side effects are perhaps the most difficult side effect to live with. They are a source of stigma, with the common misconception that movement disorders are part of the disease, rather than the treatment. ²

Drugs like procyclidine (also used in Parkinson's disease) can reduce some exptrapyramidal symptoms but have their own side effects including dry mouth, dizziness and (in high doses) cognitive difficulties such as memory problems.

Calcium channel blockers such as verapimil are sometimes used, but there is little evidence that they help tardive dyskinesia.

Vitamin E and possibly vitamin B6 may help tardive dyskinesia, with a minimum of side effects. ³. See Vitamin B6 and tardive dyskinesia

Note: for other side effects of typical antipsychotics see atypical side effects, below.

Atypical antipsychotics

Atypical antipsychotics include clozapine, risperidone, olanzapine and quetiapine. Their side effects are milder than typical antipsychotics, but they are more expensive drugs. In some countries (e.g.USA) atypical medications comprise 80% of prescriptions, but in the UK, only 16 per cent of prescriptions are for atypicals. According to the National Schizophrenia Fellowship, ⁴ this accounts for 76 per cent of all spending on antipsychotics. Doctors need to consider that atypicals, although more expensive, may be more cost-effective in the long term than typical medication.

A British Medical Journal (BMJ) clinical review ⁵ recommends that the atypical antipsychotics (except clozapine) should be given to people with a new diagnosis of schizophrenia: fewer side effects may help people to continue taking the medications and reduce the risk of relapse.

But other reviews (Geddes et al 2000) contradict this saying the atypical drugs are not significantly different from conventional antipsychotics in terms of either effectiveness or tolerability, and therefore typicals should still be considered as first-line treatment in schizophrenia.

However, clinical trials and the real world may differ; many trials are short, study samples are seldom representative of the population, and few trials include women or those with complications, such as substance misuse disorder.

The most commonly prescribed atypical antipsychotics are risperidone and olanzapine.⁴ Clozapine is particularly effective in people who have failed to respond to other drugs ⁷ , but is usually given as a last resort. This is because it is linked to a rare but potentially lethal side effect - white blood cell disruption (agranulocytosis). In the UK there are wide variations in the prescribing rates for clozapine. ⁸

A retrospective analysis of clinical trials comparing the efficacy of risperidone and olanzapine across nine countries suggests that risperidone is more effective than olanzapine, works at smaller doses, and is linked to shorter hospital stays.⁹

Side effects of atypicals and typicals

"Depixol turned me into a zombie. I lacked feelings: the ability to love, feel anger, joy or grief. I had no interest in life and could not care whether I lived or died" Christine, service user

Both atypical and typical drugs have side effects and these can be severe and disrupting. Some of the side effects mentioned are rare. Others occur more frequently, affecting certain people more than others. Side effects also depend on how long the medication has been used.

Some of the more common side effects are given below.

Short-term (acute) side effects of the antipsychotics include:

• Feelings of drowsiness, sedation and apathy
• Blurred vision and dizziness
• Inability to sit still - akathisia

Medium to long-term side effects include:

• Menstrual disruption (irregular/painful periods)
• Breast enlargement (male and female)
• Reduced sexual desire
• Weight-gain (particularly olanzapine and clozapine) ^10,11 (see below)

Rare but potentially lethal side effects include:

• Agranulocytosis (see clozapine information)
• Neuroleptic malignant syndrome - a severe form of EPS associated with typical medications

Weight gain can cause its own physical health problems including cardiovascular disease and an increased risk of diabetes mellitus. In common with reduced sexual desire and breast enlargement, putting on weight can be extremely upsetting and can also make people reluctant to continue with medication.

"I've been badly depressed when I've put on weight as a result of the medication. Who wants to regain their sanity only to find that they have to live with a body image they can't stand?" Janey, service user

Talking therapies and support

Many people with schizophrenia and their families find it helpful to talk about their feelings and experiences and to get support in coping with the illness. Talking therapies such as counselling and psychotherapy are mostly used alongside drug treatment for people with schizophrenia. Support and self-help groups can also help ease feelings of isolation and provide a place for people to talk about their feelings and share information (link to groups/orgs).

Psychological techniques have helped people who did not respond to drug treatments also. These include distracting activities, such as listening to music; behavioural tasks, such as taking exercise and cognitive tasks, such as ignoring their hallucinations. ¹²

Cognitive behavioural therapy (CBT)

CBT (most often used for anxiety and depression), has been used successfully for the symptoms of schizophrenia such as delusions or hallucinations. CBT for schizophrenia focuses on understanding, challenging and testing negative thought patterns and delusions. Between 12 and 15 weekly sessions of CBT are usually needed. See NSF fact sheet on CBT

A randomised controlled clinical trial compared the success of CBT plus routine care, supportive counselling plus routine care, and routine care alone for schizophrenia. ¹³ Significantly more people in the CBT group than in the other two groups experienced a 50% or greater reduction in symptoms. These results suggest that while CBT is not a cure for schizophrenia, it has a role in its treatment and management.

Talking therapies such as CBT are provided on the NHS by most healthcare trusts, but their availability and quality varies widely across the country. In 2000, the British Psychological Society ¹⁴ reported that only 2% of people with schizophrenia received CBT.

More information on counselling, psychotherapy and therapist in a local area is available from the British Association for Counselling and Psychotherapy

Family interventions

Families can often provide support for people with schizophrenia. When they are aware of the symptoms, family members can also notice early signs of psychosis or a relapse. Living with schizophrenia can be difficult, attitudes of friends can be unhelpful, and caring may continue for many years. This can result in major changes in family life and can affect the health of the carer.

Some mental health services offer family therapy. This can help families adjust to changes in their relative and in their own lives, by helping them to understand the illness and its treatment.

Alternative therapies

In a survey of members of the National Schizophrenia Fellowship, the Manic Depression Fellowship and Mind, 2,500 people with mental health problems were asked about their experiences of non-medical therapies. These included exercise, art/music therapy and talking therapies. Other therapies such as changing diet/nutrition, homeopathy and herbal remedies were also mentioned. The majority of people who had tried these non-medical therapies reported that they were helpful or very helpful. ¹⁵

There is also growing evidence for the benefits of other treatments alongside drug treatment for schizophrenia. For example, research findings suggest that oestrogen supplements or compounds that mimic oestrogen may have a role the treatment of women with schizophrenia.

An extract of fish oil is currently undergoing trials as a complementary therapy for schizophrenia, with a view to using similar agents as a sole treatment (Joy et al., 2000). Preliminary results are positive. Fish oil appears harmless and has no side effects. See Fish oil: what's the story on www.schizophrenia.co.uk

Vitamin E (α-tocopherol) and vitamin B6 (pyridoxine) may help to prevent extrapyramidal side effects (Najib, 1999; Lerner et al., 1999). More studies are needed, but early findings suggest that these food supplements may help reduce movement disorders resulting from antipsychotics. See Vitamin B6 and tardive dyskinesia

Future

Schizophrenia treatments that reduce the frequency and duration of hospital stays, improve functioning and are better tolerated, offer people with schizophrenia a better quality of life and may ultimately save money.

Further research may bring new and better antipsychotics; for example, iloperidone (the first depot atypical) is currently in clinical trials.

In the UK the following factors may improve schizophrenia treatment:

Impartial guidelines on atypicals and typicals?

Guidelines from the National Institute of Clinical Excellence (NICE) recommending the use of typicals or atypicals for schizophrenia may settle some of the controversy in this area. These guidelines were expected last December, but are yet to be published.

Better schizophrenia clinical trials

Evidence on the comparative effectiveness of the typical and atypical antipsychotics is not reliable. Clinical trials are of varying quality and may not be relevant to real people in the real world.

Involving people with schizophrenia

According to the recent user organisations' survey (link), more than 50% of service users are seldom, if ever, consulted about their treatment options. Almost half were not given any written information about the side effects of medication. a href="#references">¹⁵ Research like this suggests treatments will have more success if people with schizophrenia are more involved in their care.

Find out more

National Schizophrenia Fellowship fact sheets available online at http://www.nsf.org.uk/help_you/publications/treatservadv.html

References

1. Drug and Therapy Perspectives, 1999

2. Kumari et al 2000

3. Lerner et al., 1999; Miodownik et al., 2000

4. NSF leaflet, December 2000 (http://www.nsf.org.uk/help_you/publications/treatservadv.html)

5. McGrath and Emerson (1999)

7. Wahlbeck et al., 2000

8. Purcell and Lewis, 2000

9. Khtmer and Duchesne, 1999

10. Sachs GS, Guille C (1999) Weight gain associated with use of psychotropic medications. J Clin Psychiatry 60 Suppl 21:16-9

11. Baptista T (1999) Body weight gain induced by antipsychotic drugs: mechanisms and management. Acta Psychiatr Scand 100(1): 3-16

12. Shergill SS, Murray RM, McGuire PK (1998) Auditory hallucinations: a review of psychological treatments.Schizophr Res 32(3): 137-50

13. Tarrier et al. (1998) Randomised controlled trial of intensive cognitive behaviour therapy for patients with chronic schizophrenia British Medical Journal 317: 303-307

14. Jane Feinmann (2000) It's good to talk: Cognitive therapy works so why aren't people with schizophrenia getting it? Guardian June 28, 2000

15. NSF, MIND, MDF. A Question of Choice Survey 2000

Please email us with other questions you would like to see featured.