Treatment

A schizophrenia diagnosis can be overwhelming. Understanding this complex mental health disorder is often a challenge not only for those who have it, but for friends and loved ones as well. Left untreated, schizophrenia can be a devastating mental health illness, but there are many ways to manage the condition and continue living a healthy, fulfilling, and productive life.

Diagnosing Schizophrenia

Although the symptoms of schizophrenia can vary, they often present in young adulthood. In many cases, a diagnosis of schizophrenia is made for men in their late teens to early 20s and for women in their late 20s to early 30s.¹ Though first symptom onset may arise outside of these timeframes, it’s somewhat rare for a schizophrenia diagnosis to be made in children or in adults over the age of 40.

Historically, the symptoms of schizophrenia have been grouped into three categories: positive, negative, and cognitive.²

• Positive: These are categorized as “positive” because they are normally absent in healthy individuals. Psychotic symptoms of hallucinations, paranoia, and delusions fall into this category. Other positive symptoms include disordered or unusual ways of thinking as well as agitated movements.
• Negative: Negative symptoms are termed as such because they reflect deficits in emotions and behavior that are generally not present in a healthy population. Negative symptoms can include reduced emotional expression, decreased speaking, feelings of anhedonia (pleasurable activities are no longer enjoyable), and difficulty starting or completing normal activities.
• Cognitive: Symptoms affect a person’s thinking and range in severity. These can include memory loss, difficulty paying attention, and trouble applying recently learned information.

There is no quick laboratory test to confirm the presence of schizophrenia. Instead, a diagnosis of schizophrenia is made based on certain symptoms and behavioral criteria. For a diagnosis to be made, evidence of the characteristic mental and behavioral disturbances must have been present for at least 6 months.¹ The evaluating medical professional will also want to assess any drug and alcohol use to rule out other brain disorders.

In order to be diagnosed, a person must have persistently exhibited 2 or more of the following symptoms in the context of reduced functioning, with at least one of these criteria being met from the first three examples:¹

• Delusions.
• Hallucinations.
• Disorganized speech.
• Catatonic or disorganized behavior.
• Negative symptoms.

Substance Abuse and Schizophrenia

Schizophrenia occurs in approximately 1.1% of the world’s population and nearly half of those people also present with a lifetime history of substance use disorders (SUDs).^3,4 To have concurrent mental illnesses such as schizophrenia and substance use disorders is known as a dual diagnosis. Though there is a strong comorbidity between SUDs and mental illnesses, it does not necessarily mean that one caused the other.⁵

It has been hypothesized that some people with schizophrenia abuse substances as a means of self-medication—to either alleviate the burden of certain disease symptoms (e.g., sleep disturbances, social withdrawal, dysphoria) or to manage the side-effects of their antipsychotic medications.⁶ Studies indicate that individuals with schizophrenia most-commonly use alcohol, nicotine, cocaine, and marijuana.⁴ For those struggling with an SUD, schizophrenia can be even harder to identify because drug or alcohol abuse can mask or mimic its symptoms and vice versa.

Substance abuse and schizophrenia may have the following symptoms in common:

• Lack of concentration.
• Memory problems.
• Auditory or visual hallucinations.
• Delusional beliefs about oneself and others
• Unpredictable moods and behaviors.
• Inappropriate emotional affect.
• Poor judgment and high-risk behaviors.
• Withdrawal from social situations.
• Disorganized thoughts.
• Rapid, pressured speech.

SUDs can also worsen the course of schizophrenia by increasing likelihood, frequency, and intensity of psychotic episodes as well as the risk of outcomes like hospitalization, incarceration, and suicide attempts. In cases of dual diagnosis, treatment programs should use an integrated approach to treating comorbid SUD and mental illnesses. An integrated treatment approach for concurrent conditions has consistently been found to be superior when compared with the separate treatment of each diagnosis.⁵ 

Treatment

Once schizophrenia is diagnosed, consistent treatment and medical intervention are essential to managing symptoms and preventing physical illnesses associated with the disorder. According to the World Health Organization (WHO), people with schizophrenia are at a 2-3 times greater risk of dying earlier than the general population due to preventable illnesses such as infections and cardiovascular disease.⁷

The mainstay of schizophrenia management is pharmacotherapy (medications), however, nonpharmacological treatments such psychotherapy are also important in treating residual symptoms.⁸ Because schizophrenia is a chronic illness, treatment planning has several goals, including reducing or eliminating symptoms, maximizing adaptive functioning and quality of life, and promoting recovery by helping individuals set personal life goals (e.g., in work, housing, and relationships).⁴

Pharmacological Therapy

Both first (e.g., chlorpromazine, haloperidol) and second-generation (e.g., Abilify, Zyprexa, Seroquel) antipsychotic medications may be used to treat schizophrenia to effectively reduce psychotic symptoms.⁸ According to the American Psychiatric Association, many second-generation (atypical) antipsychotics (SGAs) are preferred as first-line treatment for schizophrenia over first-generation antipsychotics (FGAs) because they are associated with fewer extrapyramidal symptoms.⁸ Metabolic side effects may be more common with SGAs, including diabetes mellitus, weight gain and hyperlipidemia.⁸

During the first seven days of treatment following a psychotic episode, medications are administered to decrease hostility and return individuals to normal functioning (e.g., eating and sleeping).⁸ Drug therapy after the remission of the first psychotic episode should be continued for at least 12 months.⁸

Psychotherapeutic Approaches

Psychotherapeutic approaches may be separated into 3 categories: individual, group, and cognitive behavioral, and should be used in conjunction with medications.⁸ Individual treatments involve private therapy sessions as well as social skills and vocational therapies.⁸ Group therapy focuses on interactive/social approaches, while cognitive behavioral therapy (CBT) helps patients develop positive coping strategies for persistent symptoms that do not respond to medicine.¹ CBT may also involve family members and friends in treatment sessions and encourages them to actively participate in the individual’s treatment.⁸

Psychosocial Treatment

Psychosocial treatments enable people to eliminate or compensate for the barriers caused by the illness.¹ A person is more likely to continue taking their medication and less likely to relapse when participating in psychosocial rehabilitation.¹ Some of the more common psychosocial treatments include assertive community treatment (ACT) and peer support groups.¹ ACT provides highly-individualized services to individuals with schizophrenia to help them manage life’s daily challenges. ACT professionals also proactively address problems, ensure medications are taken, and help to prevent crises.¹

Holistic Management

Adopting a holistic approach to treatment and incorporating nutrition, exercise, and other complementary medical treatments to augment antipsychotic pharmacotherapy may have some benefit for people suffering from schizophrenia.¹⁰ For example, yoga can help counter some of the significant weight gain associated with many second-generation antipsychotics, while at the same time help manage certain negative symptoms better than pharmacotherapy alone.⁹ One study also suggested that the administration of folic acid supplements as well as vitamins B, C, and E might help improve positive and negative symptoms. While not altogether surprising that wellness activities and good nutrition might benefit certain psychopathologies, more research is certainly needed to investigate the role of complementary medicine in managing schizophrenia.⁸

With psychosocial rehabilitation, antipsychotic medication, self-management education, and family support, the lives of people struggling with schizophrenia can be vastly improved.¹

Sources

[1]. National Alliance on Mental Illness. (n.d.). Schizophrenia.

[2]. National Institute of Mental Health. (n.d.). Schizophrenia.

[3]. National Alliance on Mental Illness. (n.d.). Mental Health by the Numbers.

[4]. U.S. National Library of Medicine. (2009). Substance Use Disorders in Schizophrenia—Clinical Implications of Comorbidity. Schizophrenia Bulletin, 35(3): 469–472.

[5]. National Institute on Drug Abuse. (2018). Why is there comorbidity between substance use disorders and mental illnesses?

[6]. Department of Neuropsychology, Institute of Cognitive Neuroscience, Ruhr-University Bochum. (2013). Comorbid Substance Use Disorder In Schizophrenia: A Selective Overview Of Neurobiological And Cognitive Underpinnings. Psychiatry and Clinical Neurosciences; 67: 367–383.

[7]. World Health Organization. (n.d.). Schizophrenia.

[8]. U.S. National Library of Medicine. (2014). Schizophrenia: Overview and Treatment Options.

[9]. American Psychiatric Association. (2010). Practice guideline for the treatment of patients with schizophrenia: 2^nd edition.

[10]. U.S. National Library of Medicine. (2018). Holistic Management of Schizophrenia Symptoms Using Pharmacological and Non-pharmacological Treatment.