Schizophrenia

Essentials

• 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.

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.

Treatment Music Therapy for Schizophrenia or Schizophrenia-Like Illnesses, Social Skills Programmes for Schizophrenia, Electroconvulsive Therapy for Treatment-Resistant Schizophrenia

• 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.
• The treatment is primarily delivered in outpatient care Day Hospital Versus Admission for Acute Psychiatric Disorders, and the patient's family and close social network should be involved as far as possible.
• 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.
• Combining psychosocial therapies with the drug treatment will alleviate symptoms, improve the patient's psychosocial functioning and prevent new episodes of psychosis and hospitalization Intensive Case Management for Severe Mental IllnessMusic Therapy for Schizophrenia or Schizophrenia-Like Illnesses.
• Paying attention to the somatic health in examinations, treatment and follow-up is an essential part of good treatment of a patient with schizophrenia.

Drug treatment Chlorpromazine Versus Placebo for Schizophrenia, Haloperidol Versus Placebo for Schizophrenia, Perazine for Schizophrenia, Aripiprazole for Schizophrenia, Risperidone Vs. other Atypical Antipsychotic Medication for Schizophrenia, Risperidone Versus Placebo for Schizophrenia, Trifluoperazine for Schizophrenia, Perphenazine for Schizophrenia, Zuclopenthixol Dihydrochloride for Schizophrenia, Depot Risperidone for Schizophrenia, Quetiapine for Schizophrenia, Pimozide for Schizophrenia or Related Psychoses, Atypical Antipsychotics for People with Both Schizophrenia and Depression, Haloperidol Versus First-Generation Antipsychotic Drugs for Schizophrenia, Antipsychotic Switching for People with Schizophrenia Who have Neuroleptic-Induced Weight or Metabolic Problems, Antipsychotic Switching for People with Schizophrenia Who have Neuroleptic-Induced Weight or Metabolic Problems, Asenapine Versus Placebo for Schizophrenia, Chlorpromazine Versus Atypical Antipsychotic Drugs for Schizophrenia, Clozapine Combined with Different Antipsychotic Drugs for Treatment-Resistant Schizophrenia

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.