Online NewsLetter

A Ray of Hope for Schizophrenia Patients

Jeffrey was a quiet but generally happy child until shortly before his 18th birthday, when he started hearing voices. Within a short time, his life, and that of his family, became a living nightmare. As his condition worsened, he threatened family and friends with violence, tried to electrocute himself; threw himself in front of a truck and “confessed” to 16 crimes. Jeffrey is one of more than two million Americans with schizophrenia, the most severe of mental illnesses. At one time, someone like Jeffrey would spend all or most of his life in a mental institution. Since the development of antipsychotic medications in the 1950s, most people who suffer with the illness are able to live in the community, though seldom without occasional hospital stays. About 10 to 15 percent of homeless persons in the United States have schizophrenia.

Symptoms labeled “positive” include hallucinations, delusions and disordered thinking; “negative” symptoms include social withdrawal, lack of initiative, emotional unresponsiveness and limited speech. Antipsychotic medications such as chlorpromazine, haloperidol and fluphenazine are usually effective in reducing positive symptoms, but they cause troubling side effects–pacing, fidgeting, muscle spasms, tremors, abnormal posture, slow and stiff movements and rigid facial expressions. As a result, patients may stop taking medication, usually prompting a return to the hospital.

Refining Medications
New medications have been introduced that work much better for some patients in keeping symptoms under control. Clozapine (Clozaril), approved by the Food and Drug Administration in 1990 for use by the 30 to 40 percent of patients who do not respond to other medications, is generally more effective in treating the full range of symptoms associated with schizophrenia, and has little or no effect on body movements. Studies have found that patients are less likely to quit taking clozapine than medications such as haloperidol, and are much more likely to improve to the point that they can be discharged to the community. One 12-month retrospective study found that clozapine reduced the rate of re-hospitalization by 83 percent and had a significant effect on the patient’s ability to respond to vocational rehabilitation. Although clozapine is much more expensive, one study published in the New England Journal of Medicine found that, because of the lower rate of hospitalization, a year’s treatment with clozapine was no more costly than a year on haloperidol.

Clozapine has been found 15 to 25 percent more effective than conventional antipsychotic medications in reducing symptoms; in a few cases, improvement has been dramatic enough to approach total remission, even after many years of chronic illness. But the drug is not without side effects, including an increased risk of seizures and of agranulocytosis, a potentially fatal decrease in the blood count of infection-fighting white cells. The success of clozapine has stimulated the development of other drugs that have at least some of the virtues of clozapine without the risk of agranulocytosis. These include risperidone, olanzapine, quetiapine and ziprasidone. Others are being investigated.

These new drugs are still called “atypical,” primarily because they don’t produce the movement-related symptoms of earlier antipsychotic medications. They are already widely used and will become even more valuable as they become available in depot form—so they can be injected into muscles once a month for slow absorption, thus assuring a steady dose.

Non-Drug Approaches
As medications become more effective at controlling the troubling symptoms of schizophrenia, other treatment approaches will become even more important in providing psychiatric and social rehabilitation. Since schizophrenia typically strikes before age 20, before identity development is complete, many patients are much less mature than their chronological age indicates. They need considerable help in social relationships and problem solving before they can hope to live with any degree of independence. As negative symptoms improve, they may become more vulnerable to emotional stress.

After hospitalization for an initial psychotic episode, about two-thirds of patients return to live with their parents. When families have realistic expectations and training in the nature of the illness, effects of medications, and signs of relapse, then relapse rates go down.

Most patients and their families are happier when the patient has his or her own room or apartment with someone to check in occasionally, supervise medications and get help in an emergency. The National Institute of Mental Health has conducted numerous demonstration projects on supported housing. Most patients also do better when they have a chance to work, preferably in a real job, with follow-up support.

Health care professionals advocate integrated treatment services—supervising medications, helping manage finances and employment, monitoring health care, counseling families and getting help in a crisis. A study at Yale found that patients in integrated programs had less depression, fewer symptoms, a lower rate of drug and alcohol abuse and a better chance of maintaining themselves in independent housing.

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Last modified: Monday, April 14, 2014

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