Prodromal and initial symptoms of psychosis should be identified at the early phase.
Specialized psychiatric care should be provided as early as possible, preferably before the first episode of psychosis.
Treatment aims to eliminate or alleviate symptoms, prevent new episodes of psychosis and improve psychosocial performance and quality of life.
Treatment consists of pharmacotherapy combined with psychosocial therapies. After the initial phase, the treatment is primarily delivered in outpatient care. In long-term treatment, active commitment of the patient, somatic health care and flexible services in case of crisis are important.
Aetiology
The stress-diathesis model may be used to explain the development of schizophrenia. According to this model, genetics and/or early development contribute to a predisposition towards the disease, and a stress factor triggers the disease.
The most important predisposing factor is genetic but only a small proportion of schizophrenic patients have a close relative with the same condition. Disturbed foetal development, complications of labour and childhood traumas may also increase the risk of schizophrenia.
Developmental demands associated with growing up, moving from one educational level to the next, forming a relationship or working may act as the stress factors that trigger the disease, or the disease may be triggered by a toxic factor, such as the abuse of illicit drugs.
Epidemiology
Schizophrenia usually starts in early adulthood, in men earlier than in women. It is also more common in men than in women (1.4:1).
The annual incidence of schizophrenia is approximately 2 cases per 1 000 inhabitants and its prevalence within the population is approximately 0.5-1.5%.
There are about 55-65 000 patients with schizophrenia in Finland (about 1-1.2% of population).
Diagnosis
Diagnosis is made by a psychiatrist with the assistance of a multidisciplinary team. The diagnostic workup consists of a clinical interview, family interview, physical and neuropsychological examinations.
In addition, the initial assessment includes assessment of social and occupational functioning and of the situation of the patient's children.
Diagnosis is based on the presence of symptoms typical for schizophrenia of at least one month's duration and reduced functional capacity.
Physical and laboratory investigations are used to rule out somatic diseases that may present with psychotic symptoms (for example, neurological and endocrinological diseases, see Mental Disorders Due to Somatic Disease) and psychosis induced by intoxicant abuse.
Symptoms
Patients with schizophrenia have positive and negative symptoms, as well as cognitive deficits.
Depression and anxiety often also occur in connection with schizophrenia.
In the acute phase, the patient almost always has hallucinations, delusions and incoherence.
A schizophrenic patient may be suicidal both during the acute phase and during the immediate postpsychotic recovery phase.
Schizophrenia is almost invariably associated with withdrawal from social contact and a diminished ability to study or work as well as reduced functional capacity.
Positive symptoms of schizophrenia (hallucinations, delusions and incoherence)
Auditory hallucinations, particularly voices commenting on the patient's behaviour and discussing with each other, are typical. Somatic hallucinations are also possible; the patient may, for example, feel the presence of a device of some sort within the brain. Olfactory, gustatory and tactile hallucinations are also possible.
Visual hallucinations are uncommon and are suggestive of organic brain dysfunction.
The most common delusions are delusions of persecution, delusions of reference and delusions of control. Patients may feel that they are being followed or persecuted, or that references or messages to them appear in newspapers or on the radio, or that they are being influenced by, for example, telepathic means. A severely paranoid patient may be dangerous.
Incoherence presents as disorganization of thought, cessation in the flow of thought, abnormal associations and concretization of thought.
Negative symptoms of schizophrenia
The negative symptoms of schizophrenia describe the lack of motivation and interest associated with the disorder, as well as flattening of expression.
Lack of motivation and interest manifest as inability to feel pleasure, lack of will, apathy and social withdrawal.
Flattening of expression appears as poverty of speech and reduced emotional expression.
Cognitive symptoms of schizophrenia
Cognitive deficiencies occur with regard to e.g. attentiveness, executive function, memory, information processing and perception, as well as in general cognitive capacity.
Somatic comorbidities
Somatic diseases are common in patients with schizophrenia, such as cardiovascular or metabolic diseases (e.g. type 2 diabetes and MBO), low vitamin D concentration, impaired bone health, pulmonary or oral diseases.
Prodromal symptoms
Psychosis may be preceded by a phase during which anxiety and depression occur, as well as mild psychotic symptoms, such as feelings of change in one's environment or in oneself, or of being followed or observed, or short-lasting illusions or hallucinations. When suspecting prodromal symptoms, the patient should be referred for an evaluation within specialized care.
The recommended primary therapy for prodromal symptoms is cognitive-behavioural psychotherapy http://www.dynamed.com/condition/schizophrenia#PREVENTION .If the symptoms are severe or progressive, it is worthwhile to start a second-generation antipsychotic drug, combined with the psychotherapy.
The cornerstone of treatment and rehabilitation is a long-term, understanding and trusting therapeutic relationship.
The treatment of schizophrenia should be patient-oriented and take into account the patient's individual needs. The treatment should be discussed with the patient unless the disease renders discussion impossible.
The treatment should be based on a written care plan reviewed at fixed intervals.
The aim of treatment and rehabilitation is to remove or alleviate symptoms, prevent the recurrence of episodes of psychosis or reduce their frequency and severity, as well as to improve psychosocial functioning, work ability and quality of life.
In the treatment of schizophrenia one should be prepared for crisis situations, where the patient, for example, becomes ill with a somatic disease or in an unplanned manner drops out from care. Active approach and intensive support for the patient are required in such situations.
Antipsychotic drug treatment markedly decreases the symptoms of acute psychosis, new episodes of psychosis and mortality.
Paying attention to the somatic health in examinations, treatment and follow-up is an essential part of good treatment of a patient with schizophrenia.
Acute care
Any severely psychotic patient should be referred for hospital treatment http://www.dynamed.com/management/medications-for-schizophrenia#INITITAL_APPROACH_TO_MANAGEMENT. A hospital referral is indicated for a psychotic patient, if necessary without the consent of the patient (under appropriate legislation), if the patient exhibits self-destructive or violent behaviour, if his/her behaviour is strongly guided by hallucinations or delusions or if the local outpatient resources are inadequate to manage the examination and treatment of the patient.
When planning medication, it is important to bear in mind the patient's previous experience with drug treatment since the susceptibility to different types of adverse effects varies from patient to patient.
The lowest effective daily dose should be sought by gradually adjusting the dose. This will avoid the emergence of drug-induced adverse effects and improve compliance.
After the period of psychosis, the dosage should be gradually lowered under close monitoring of the patient's condition. When the maintenance dose has been achieved, the treatment may be continued either as tablets or as depot injections.
Doses used in long-term therapy are usually markedly lower than those used in acute situations. In long-term treatment of schizophrenia, the daily dose may be, for example, 8-24 mg perphenazineor 2-5 mg risperidone.
Depot injections may be useful, particularly if the patient's awareness of illness is defective. In depot injection treatment, it is recommended to use single doses that are lower than usual, e.g. 25-50 mg risperidone every 2 weeks, paliperidone 50-100 mg or aripiprazole 300-400 mg at 1-month intervals.
Clozapine Clozapine Therapy is more effective than other antipsychotics. Its use is associated with lower mortality than that associated with other antipsychotics. Clozapine is the drug of choice in the treatment of schizophrenia refractory to other medication.
Usually patients with schizophrenia require long-term drug therapy. Prophylactic antipsychotic treatment against relapses should continue for at least 2-5 years even after treatment response has been achieved Maintenance Treatment with Antipsychotic Drugs for Schizophrenia.
Withdrawal of the medication must be gradual and the patient should be closely monitored for the emergence of symptoms predictive of psychosis. Should any such symptoms emerge, the medication should be increased to its earlier effective level.
The use of antipsychotics may be associated with parkinsonism and extrapyramidal symptoms, such as stiffness, dystonia or akathisia. Particular attention should be paid to involuntary muscular movements of the mouth, tongue, eyes and neck.
Acute neurological adverse effects of antipsychotic drugs should be treated with transient anticholinergic medication (e.g. 2-6 mg biperiden) and the antipsychotic medication or its dosage subsequently changed so that the adverse effects disappear.
Long-term anticholinergic medication should be avoided.
All antipsychotics, particularly sertindole and ziprasidone, may increase cardiac QT intervalLong QT Syndrome (LQTS).
In order to prevent metabolic adverse effects, to diagnose them and start their treatment early, the patient's physical health should be regularly monitored: the patient's body mass index, waist measurement, blood pressure, as well as glucose and lipid values must be measured/determined.
Psychoeducation reduces the symptoms of schizophrenia, improves drug compliance as well as the social functioning of the patients and the wellbeing of their families, and reduces the recurrence of episodes of psychosis Psychoeducation (Brief) for People with Schizophrenia.
Inclusion of the family in a psychoeducational approach will reduce the recurrence of psychoses and the number of periods of hospital treatment and improve compliance with pharmacotherapy.
The situation of children in the family should also be investigated and measures appropriate in each situation taken in cooperation with experts in child psychiatry and with welfare authorities.
Successful withdrawal from smoking and regular physical exercise have positive effects also on patients' cognition, mental health and quality of life.
Staging the treatment
The task allocation between primary and specialized health care depends on local circumstances and resources.
A schizophrenic patient seen for the first time must be referred to specialized care.
Patients with poorly controlled schizophrenia need specialized care. The treatment of patients whose disease is well controlled can be managed in primary care and a psychiatrist consulted as necessary.
Clozapine therapy Clozapine Therapy is started in specialized care. Follow-up treatment including monitoring of blood neutrophil counts can take place in primary care.
Prognosis
Schizophrenia is a serious and chronic disease.
More than half of schizophrenic patients will make a reasonable recovery, but about one in ten patients need help with daily activities.
The course of the disease is often variable: the patient may have repeated episodes of psychosis but may be almost free of symptoms in between times.
The age-adjusted mortality of schizophrenic patients is 2-3 times as high as in the general population. The excess mortality of patients with schizophrenia is mainly due to general diseases, such as cardiovascular, metabolic or respiratory diseases.
In younger age groups, the excess mortality compared to the general population is mainly due to suicides; 5% of patients with schizophrenia commit suicide.
Mortality is highest among patients not taking antipsychotic medication. Also long-term use of benzodiazepines increases mortality.
Monitoring the effectiveness of treatment
Following up the realization of treatments defined in the patient's treatment plan and monitoring the changes in his/her clinical and functional condition belong to the good treatment of a patient with schizophrenia.
References
Schmidt SJ, Schultze-Lutter F, Schimmelmann BG et al. EPA guidance on the early intervention in clinical high risk states of psychoses. Eur Psychiatry 2015;30(3):388-404. [PubMed]
Tiihonen J, Lönnqvist J, Wahlbeck K et al. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). Lancet 2009;374(9690):620-7. [PubMed]
Daumit GL, Goff DC, Meyer JM, et al. Antipsychotic effects on estimated 10-year coronary heart disease risk in the CATIE schizophrenia study. Schizophr Res 2008 Oct;105(1-3):175-87. [PubMed]
Barnett AH, Mackin P, Chaudhry I et al. Minimising metabolic and cardiovascular risk in schizophrenia: diabetes, obesity and dyslipidaemia. J Psychopharmacol 2007;21(4):357-73. [PubMed]
Perälä J, Suvisaari J, Saarni SI, et al. Lifetime prevalence of psychotic and bipolar I disorders in a general population. Arch Gen Psychiatry 2007 Jan;64(1):19-28. [PubMed]