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Getting to grips with schizophrenia

Case report

John was a 20-year-old university student with no family history of mental illness. While attending college, he began to distance himself from his family and friends. Over a period of around a year, his grades slipped, he stopped phoning home, and John rarely socialised with his friends. One of his friends phoned John’s parents to say that John was acting strangely and smoking cannabis daily. John’s parents visited and saw nothing in particular amiss, but felt that John seemed slightly distracted during their visit.

Three months later, John presented to a hospital emergency department in a highly distressed state, saying that there were unusual ‘forces’ at work on the Internet and he needed to come to hospital. On further questioning, John stated that various common websites had started to send messages specifically to him, warning him that ‘dark forces’ were at work. John said he did not actually hear voices, but had ‘a feeling of voices’ coming from outside his head. John added that the relevant websites were now controlling some of his thoughts.

Following complete history, mental state examination and physical assessment, John allowed his parents to be telephoned and they came to the hospital. It was agreed that John would start taking an antipsychotic medication, cease smoking cannabis, and stay with his parents for the time being. John seemed relieved with the arrangements, although still perplexed.

Follow-up by a community mental health nurse the next day revealed that John’s mental state was generally unchanged, and he remained agreeable with the treatment plan. Over the following week, John’s paranoid delusions began slowly to subside and he became substantially less distressed. His parents contacted the college and John opted to take some weeks off his course. Psycho-education was provided to John and his family, focusing on the nature of John’s symptoms, the role of medication and other therapies, the advisability of avoiding cannabis and other drugs, and steps to be taken in the event of any future deterioration in mental health.

Discussion

The morbid lifetime risk of schizophrenia is approximately 1 per cent, with 15 new cases occurring per 100,000 population per year, an incidence equal to that of type 1 diabetes in Western Europe. In Ireland, schizophrenia accounted for 20 per cent of all psychiatric admissions in 2014, yielding the second-highest admission rate of any diagnosis (77.2 admissions per 100,000 population), second only to depressive disorders (105.3) (Daly and Walsh, 2015). Schizophrenia had the highest rate of involuntary admission in 2014 (18.9 per 100,000), followed by mania (8.7 per 100,000) and depressive disorders (4.5 per 100,000).

In societal terms, schizophrenia exerts substantial economic costs: In 2000, the annual cost of schizophrenia to the US was $40 billion (€37 billion) — three times as much as the US space programme (Torrey, 2001). In 2002, the estimated cost in the US had risen to $63 billion (€58 billion), including $23 billion (€21 billion) in direct healthcare costs.

‘The true cost of schizophrenia can only be described in human terms, relating to reduced quality of life, limited opportunity for personal development, ongoing morbidity and increased mortality, as well as the suffering and stress of family members and carers’

In England, the estimated societal cost of schizophrenia was £7 billion (€10 billion) in 2004/2005, while in Ireland the cost of schizophrenia in 2006 was €460.6 million, comprising direct costs of care amounting to €117.5 million and indirect costs of €343 million, including €43.8 for informal care borne by families (Behan et al, 2008). Lost productivity due to unemployment, absence from work and premature mortality came to €277 million.

The true cost of schizophrenia, however, can only be described in human terms, relating to reduced quality of life, limited opportunity for personal development, ongoing morbidity and increased mortality, as well as the suffering and stress of family members and carers. Much of this is attributable to the broad range of positive and negative symptoms associated with the disorder.

Diagnosis

Key symptoms of schizophrenia relate to thinking, emotion, behaviour and judgment, and are outlined in the International Classification of Diseases (10th Edition) (ICD-10) (World Health Organisation, 1992). According to ICD-10, a diagnosis of schizophrenia requires either one major symptom or two minor symptoms to be present for most of the time during an episode of psychotic illness lasting for at least one month, or else at some time during most of the days.

The major symptoms of schizophrenia are (a) thought echo, thought insertion, thought withdrawal, or thought broadcast; (b) delusions of control, influence or passivity, referring to body or limb movements or specific thoughts, actions, or sensations or delusional perception; (c) auditory hallucinations of voices giving a running commentary on the person’s behaviour, or discussing the patient between themselves, or other hallucinatory voices emanating from the body; and (d) other kinds of persistent delusions that are culturally inappropriate and completely impossible.

Minor symptoms include (a) persistent hallucinations in any modality, occurring every day for some weeks, accompanied by delusions (which may be fleeting) without clear mood-related content or persistent over-valued ideas; (b) various kinds of thought disorder, such as neologisms, breaks or interpolations in thought, with resulting diminished coherence; (c) catatonic behaviour (eg, posturing or waxy flexibility, excitement, mutism, negativism, stupor); and (d) negative symptoms (eg, emotional blunting or incongruity,  paucity of speech, marked apathy), which are not attributable to medication or depression. There may also be consistent and significant change in other aspects of behaviour (eg, social withdrawal). For a diagnosis of schizophrenia, these symptoms must not be attributable to alcohol or drugs (intoxication, dependence or withdrawal) or organic brain disease.

Risk factors

The biological underpinnings of schizophrenia are not fully understood. The disorder probably results from a complex interaction of inherited genetic predispositions, disruptions to nervous system development prior to birth, and further contributory factors acting in adolescence and early adulthood. One particularly convincing model implicates developmental alterations resulting from variant genes; early insults to the brain, and childhood adversity (which may sensitise the dopamine system); social adversity (which biases cognitive schema used to interpret experience); subsequent stress, which may result in dysregulated dopamine release leading to misattribution of salience to certain stimuli, which are, in turn, misinterpreted by biased cognitive processes; and further stress resulting from hallucinations and paranoia, eventually resulting in hard-wiring of psychotic beliefs by repeated dopamine dysregulation (Howes and Murray, 2014).

There may well be myriad individual variations on this kind of model, but it is now clear that it is composite causal models such as this one that best synthesise current understandings of risk factors for schizophrenia. More research needs to be done to elucidate precise causal pathways and aetiological models, and, indeed, establish the extent to which ‘schizophrenia’ (as currently conceived) constitutes a unitary disorder or, alternatively, a common end point for a variety of different developmental and pathological processes unfolding over time.

Treatment

Schizophrenia is a treatable mental disorder. As is the case with all mental disorders, treatment is based on a biopsychosocial approach. Biological interventions include administration of psychotropic medications, treatment of comorbid medical or substance-related disorders, and, in certain cases, electroconvulsive therapy (ECT). Psychological and social interventions include specific psychotherapies for patients and families, as well as enhancing social supports and participation.

The UK National Institute for Health and Care Excellence (NICE) provides specific treatment recommendations in its Review of Psychosis and schizophrenia in adults: Prevention and management, published in February 2014 and freely available from its website (www.nice.org.uk/guidance/cg178). The NICE advice covers a range of areas relating to schizophrenia, but places especially strong emphasis on early intervention for first-episode psychosis, for which NICE recommends oral antipsychotic medication in conjunction with psychological interventions (eg, family interventions, individual cognitive behaviour therapy).

NICE also recommends that the choice of antipsychotic medication is made by the patient and healthcare professional (and, if appropriate, carer) together, taking account of likely benefits and adverse effects of each option, including possible metabolic consequences (eg, weight gain), extrapyramidal side-effects (eg, dyskinesia, dystonia, akathisia), cardiovascular effects (eg, QT interval prolongation), hormonal changes (eg, raised prolactin) and various other possibilities. There is now a broad range of antipsychotic medications available, with different combinations of benefits and adverse effects, so there are many options to choose from.

For subsequent episodes of psychosis, NICE recommends offering crisis resolution and home treatment once the risk profile and severity of the episode are consistent with this. Again, they recommend a combination of pharmacological and psychological treatments, taking into account the factors listed above, along with information gleaned from previous episodes of treatment.

The range of antipsychotic medications available includes both oral and injected formulations, depending on patient need and preference. Further guidance on specific medications is provided in the widely-used Maudsley Trust Prescribing Guidelines in Psychiatry (12th Edition) (Taylor et al, 2015). For a small minority, ECT may be indicated at certain times.

Conclusions

Schizophrenia is a relatively common mental disorder, which can be disabling but is treatable. One of the key long-term challenges in therapy is the recurring finding that schizophrenia is associated with poor physical health. Life expectancy is considerably reduced: On average, men with schizophrenia die 15 years earlier, and women 12 years earlier, than the rest of the population. This excess is not accounted for by unnatural deaths; the leading causes are heart disease and cancer. As a result, there is a need for ongoing and enhanced focus on the physical health of persons with schizophrenia, including but not limited to support in stopping smoking, promotion of improved diet and lifestyle, and screening for cardiac risk factors.

While most persons with schizophrenia do survive until middle age, it is recognised that the illness is associated with increased risk of suicide and reduced rates of social interaction, marriage and reproduction. Schizophrenia is also associated with reduced workforce participation, with the result that two-thirds of persons with chronic schizophrenia are unemployed. This is a key issue for patients, families and society in general, as the Scottish Government highlighted, with particular emphasis in its Mental Health Strategy for Scotland, 2012-2015: “We know that being in the right work is good for a person’s health and improves their quality of life and wellbeing. This is also true for people with a mental or physical health condition. Remaining in, or returning to work quickly, aids recovery and more people gain health benefits from being in work than are negatively affected by it. However, people with mental illness are less likely to be engaged in work than the general population or those with other health conditions, with one review identifying that 79 per cent of people with serious, long-term mental health problems are not in employment. Improving and increasing access to employment for those with mental illness is challenging, but necessary and achievable…

“There is an evidence base that shows that, with the right kind of help, people with serious mental health problems can successfully get and keep work. This applies irrespective of individual characteristics, such as clinical history or previous employment. A Cochrane systematic review found that those with severe mental illness who received supported employment were two or three times more likely to be in competitive employment at 12 months.” (pp 44-45)

Equal access to the workforce is a fundamental economic and social right. People with schizophrenia commonly experience violations of this right, along with de facto violations of the right to liberty (ie, increased rates of imprisonment, often for minor offences) and various other rights (eg, the right to appropriate housing). Remedying this persistent discrimination, reducing stigma and combating social exclusion of the mentally ill (including those with schizophrenia) is a task not just for health professionals, but also for patients and their families, service-user groups and the politicians who shape mental health policy and social services in Ireland.

Acknowledgement

This article contains Scottish Parliamentary information licensed under the Open Scottish Parliament Licence v1.0.

References available on request

ECT for schizophrenia

NICE, following an extensive review of evidence, recommends ECT for severe depressive illness, prolonged or severe episodes of mania, or catatonia (which can occur in schizophrenia), once certain conditions are met. According to NICE, ECT should be administered to gain fast, short-term improvement of severe symptoms after all other treatment options have failed, or when the situation is life-threatening. Particular caution is advised in pregnant women and older or younger patients; an individual risk-benefit assessment should be performed (balancing adverse effects, such as memory problems, with benefits); and patients should be reassessed regularly during programmes of ECT.

More than one course of ECT should be considered only for patients with severe depressive illness, catatonia or mania who have previously had good responses to ECT. ECT should not be used to prevent recurrence of depression or in the general management of schizophrenia, according to NICE.

ECT should, then, be reserved for rare, severe situations in persons with schizophrenia. In Ireland, schizophrenia, schizotypal and delusional disorders accounted for less than 9 per cent of all programmes of ECT administered in 2013, the vast majority being prescribed for depressive disorders (82 per cent) (Mental Health Commission, 2015). Nonetheless, there remains a small minority of patients with schizophrenia, especially those with catatonia, for whom ECT is indicated and effective.

Source: National Institute for Health and Care Excellence (NICE). Guidance on the Use of Electroconvulsive Therapy(www.nice.org.uk/guidance/ta59).

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