The Ongoing Challenges of Schizophrenia

Schizophrenia is a complex mental health condition that impacts a person’s feelings, thoughts, behaviors, and perception of reality. When symptoms are severe, the condition can reach a debilitating level and affect every area of life.

Though antipsychotic medications can manage the positive symptoms (hallucinations and delusions) of schizophrenia, these drugs often come with unwanted side effects for many people.

In addition, there are still no effective treatments to manage the ongoing negative and cognitive symptoms of schizophrenia. This lack can make it difficult to work and function in daily life.

Thus, many people with schizophrenia continue to live with the following challenges:

• untreated negative symptoms
• medication side effects
• weight management
• suicidal thoughts
• substance use
• job challenges

The negative symptoms of schizophrenia reduce or “take away” from someone’s personality. These symptoms often relate to motivation, interests, or verbal and emotional expression.

Up to 60% of people with schizophrenia live with negative symptoms that are significant enough to require treatment.

Negative symptoms consist of five key areas:

1. difficulty expressing emotions, e.g., diminished facial expressions (called blunted- or flat affect)
2. reduction in the number of words spoken (alogia)
3. reduced goal-directed activity due to decreased motivation (avolition)
4. reduced social activity (asociality)
5. reduced experience of pleasure (anhedonia)

Negative symptoms don’t respond to current antipsychotic medications, and so they tend to be the most persistent and difficult aspect of the disorder for many people.

Negative symptoms account for a large part of the disorder’s long-term disability and functioning difficulty. Treatment for these symptoms is still considered an urgent unmet need in psychiatry.

People with schizophrenia who regularly take atypical antipsychotics may experience numerous side effects.

A 2020 study of 435 participants reported the following medication side effects:

• sleepy during the day (about 83% of participants)
• difficulty sleeping (around 75% of participants)
• dry mouth (almost 64% of participants)
• problems enjoying sex (around 53% of participants)
• weight gain (about 52% of participants)

Research from 2018 suggests that about half of people treated with atypical antipsychotics develop metabolic complications, including:

• weight gain
• insulin resistance
• abnormal cholesterol

These side effects may make people not want to take their medication.

One survey found that 26.5% of people with schizophrenia weren’t taking meds as prescribed, while another study found that percentage closer to 70%. Not taking prescriptions is linked to an increased chance of psychosis relapse, persistent symptoms, and suicide attempts.

Obesity is twice as common in people with schizophrenia as in the general population. It’s also linked to significantly worsened mental and physical health.

Several factors may contribute to weight gain in those with schizophrenia:

• antipsychotic medication
• sedentary lifestyle
• largely consuming processed food
• genetics

Most antipsychotic medications cause weight gain. Weight tends to increase rapidly in the initial period after starting these medications. Up to 86% of those with first-episode psychosis experience more than 7% of body weight gain in the first year of treatment.

These medications may increase weight via the following mechanisms:

• increased appetite
• altered gut microbiome
• impaired glucose metabolism

Research from 2017 suggests that the most weight gain is caused by:

• olanzapine
• clozapine
• zotepine

Ziprasidone was shown to cause the least weight gain.

Still, each individual with schizophrenia will respond best to a particular medication, so it’s important to take the one that most effectively reduces your symptoms with the fewest side effects.

Suicide is a cause of early death in nearly 5% of people with schizophrenia. And 25% to 50% attempt suicide in their lifetime.

The following factors may further increase the chances of suicidal behavior:

• being born male
• younger age
• being unmarried
• lack of family support or disrupted family relationships
• previous suicide attempt
• adverse childhood experiences
• early onset of schizophrenia
• current depressive disorder (A 2021 study found that more than 50% of people who died by suicide had symptoms of depression at the time of the suicide.)
• hopelessness or demoralization
• insomnia
• co-occurring substance use disorder

The following factors may help reduce likelihood of attempting suicide:

• sound coping strategies
• social support
• insight into schizophrenia
• absence of psychotic symptoms
• good relationship or collaboration with clinician

Research from 2021 suggests that certain antipsychotic medications may be more effective at reducing suicidal thoughts:

• clozapine
• risperidone
• olanzapine
• quetiapine

People with schizophrenia are 3 to 6 times more likely to have a substance use disorder (SUD) compared to the general population. Up to 50% of individuals with schizophrenia are either alcohol- or drug dependent. More than 70% are nicotine dependent.

A large study found that 27.1% of people with schizophrenia have had a cannabis use disorder in their lifetime.

Alcohol and substance use disorders can also increase the possibility of suicide. People with a SUD are nearly six times more likely to report a lifetime suicide attempt than those without a SUD. In particular, the use of stimulants (cocaine, amphetamine) increases the chances of attempted suicide.

Substance misuse contributes to an increased risk of psychosis. For many people, substance-induced psychosis is short-term, but in other cases, the symptoms may persist, mimicking the positive and negative symptoms of schizophrenia.

Working can be a challenge for many people with schizophrenia, though it is possible to have a job. According to the World Health Organization, schizophrenia is the fourth leading cause of disability.

One 2020 study found that only 3% to 4% of folks with the disorder were employed, while about the same number were on long-term sick leave. Over 80% were on a disability pension.

If you or a loved one lives with schizophrenia, then you’re likely aware of the ongoing challenges the disorder can bring.

Researchers are working to develop better solutions for these unmet needs. It’s likely that in the near future, many of these challenges will be addressed with new and effective interventions.

These may include:

• antipsychotic medications with fewer side effects
• better interventions for substance use disorder
• effective treatments for schizophrenia’s negative and cognitive symptoms

Meanwhile, if you want the learn more about managing schizophrenia in everyday life, you can check out our schizophrenia hub.