Schizophrenia is a complex and often chronic illness that requires long-term treatment. Medication is the bedrock of managing schizophrenia, said Peter Buckley, MD, a psychiatrist and expert in schizophrenia, and dean of the Medical College of Georgia at Georgia Regents University.
But a comprehensive plan, which includes familial support and education, and considers the person’s individual psychological needs, is key, he said.
The specifics of treatment depend on the stage of the illness and the person’s age, said Robert Buchanan, MD, director of the Maryland Psychiatric Research Center and a leading expert in schizophrenia. “Someone who is having a first episode of psychosis might have a different treatment plan than someone who is 45 and has been ill for many years.”
Taking an Active Role in Treatment
“The most effective way to treat the illness is for the person to learn about the disorder and its symptoms, and to take an active role in their treatment,” said Susan Gingerich, MSW, a clinician based in Philadelphia with over 30 years of experience working with individuals with schizophrenia and their families.
That includes focusing on life goals that are important to you, such as working, going to school or having close relationships, she said.
It also includes other key elements: taking medication as prescribed; learning to manage stress and symptoms; avoiding drugs and alcohol; developing and using a relapse prevention plan; sticking with treatment; and building a social support network, she said.
Because schizophrenia tends to be a lifelong illness, it requires lifelong management with medication. Finding the right medication is a trial-and-error process. “There are no predicators for which drug will be most effective for a particular individual,” Buchanan said. That’s why having a collaborative relationship with the prescribing physician is so important.
Medication adherence is a big challenge. In the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE), 74 percent of patients stopped taking their medication within the first 18 months of treatment. Not taking medication increases the risk for relapse, hospitalization and suicidal behavior.
“Adherence seems very simple, but it’s actually remarkably complicated,” Buckley said. The reasons people don’t take their medication differ with each individual, he said. The most common reason is lack of awareness of being ill. As Buckley said, if you don’t consider yourself psychotic, why would you take an antipsychotic medication?
There are gradients of insight, and insight may fluctuate, Buchanan said. For instance, “a person may not have insight into their illness, per say, but they may know that they’re having trouble going outside of their house and feeling comfortable.” In supportive therapy, the therapist and patient may talk about how medication can help them achieve their goal of feeling comfortable with leaving their house, he said.
Individuals also might not take medication because it doesn’t work or has bothersome side effects. Substance abuse is common, and may contribute to non-adherence, as well.
Other factors include the disapproving opinions of family members and others’ bad experiences with medication, Buckley said.
Plus, “lots of people don’t take their medicines exactly as prescribed.” For instance, individuals who’ve been taking blood pressure medication for many years also slip up, he said.
According to Buchanan, a collaborative relationship between the psychiatrist and patient is critical in enhancing adherence. In fact, another reason people don’t take medication is because they feel pressured or “ordered” to take it “without having been involved in shared decision-making,” said Gingerich, also co-author of The Complete Family Guide to Schizophrenia, Social Skills Training for Schizophrenia, and Illness Management and Recovery: Personalized Skills and Strategies for Those with Mental Illness.
It’s important to have open discussions around what the patient finds helpful about the medication and what they don’t like, Buchanan said. This way they can make adjustments and try different medications, he said.
Sometimes, people don’t like taking pills or because of their cognitive impairment, they have a hard time remembering to take their medication, Buchanan said. One strategy is to incorporate medication into the person’s daily routine, Gingerich said.
For instance, this can include “putting one’s pill bottle next to their tooth brush so they are reminded to take their medication when they brush their teeth,” along with using pill organizers and setting up cues “such as using a calendar, or programming one’s cell phone.”
Another strategy is “offering the option of long-acting injectable medication. Instead of taking a pill every day, [patients] can receive a shot once every two weeks or four weeks,” Buchanan said.
“Psychosocial interventions are a cornerstone of the comprehensive treatment of patients with schizophrenia, and when used in combination with medication, they are more effective than antipsychotics alone,” write Buckley and Brian Miller, MD, PhD, in the 2013 edition of Conn’s Current Therapy.
This can include educating families about schizophrenia and the best ways to offer support. Having loved ones involved in treatment can increase medication adherence and decrease relapse rates.
Other interventions include social skills training, which teaches individuals with schizophrenia to be assertive, resolve conflict and navigate work issues.
Supported employment helps people find and keep jobs in the community based on their abilities and preferences. It includes “individually tailored job development, rapid job search, availability of ongoing job supports, and integration of vocational and mental health services,” according to this 2009 research-based summary of psychosocial treatments. Supported employment helps in building self-esteem and self-image, Buchanan said.
Cognitive-behavioral therapy (CBT) aims to treat the positive symptoms of schizophrenia, such as hallucinations and delusions, and negative symptoms, such as lack of motivation. It also helps individuals identify their recovery goals and work toward them. And it helps with any co-occurring disorders such as depression and anxiety.
Treating Substance Use
Substance abuse is the most common co-occurring disorder for people with schizophrenia. When a person has both schizophrenia and issues with substance use, “it is important to get treatment from professionals who treat the disorders concurrently and in an integrated way,” Gingerich said.
This treatment is typically called “Integrated Treatment for Dual Disorders” or “Co-Occurring Disorder Treatment.”
According to Gingerich, it usually includes these areas: helping the person identify why they are using substances (for instance, it might be to cope with symptoms); talking about how they can get these same needs met without turning to drugs or alcohol; helping them identify the harmful consequences of their use, such as relapse or legal or relationship problems; “helping the person weigh the pros and cons of sobriety”; and “identifying high-risk situations and ways to avoid them or cope with them.”
It also includes helping the person make a plan for reducing their use or stopping it altogether, when they’re ready, she said. And it includes gathering support, “from groups such as Dual Recovery Anonymous and from sober friends and family.”
Peer counseling can be very helpful and take various forms. It tends to be similar to Alcoholics Anonymous, as individuals who are living successfully with schizophrenia are trained to help others with the illness. They may help with everything from sharing insight into navigating the mental healthcare system to providing information on managing stress and symptoms.
You can learn more about peer services and support at the National Alliance on Mental Illness.
Antipsychotic medication doesn’t help with the debilitating cognitive deficits schizophrenia causes, which affect nearly all patients. That’s why researchers also are exploring the efficacy of cognitive remediation.
This is a behavioral training-based intervention that aims to improve cognitive processes, such as attention, memory and executive function. Most cognitive remediation programs use computers and target one or several cognitive skills.
Often, it’s the cognitive symptoms that are most damaging to a person’s ability to work, study and even live independently. Cognitive deficits make it harder to remember and process information. Individuals may have a difficult time with everything from remembering their supervisor’s instructions to maintaining a budget to navigating public transportation.
As this piece points out, “Sometimes patients are labeled as unmotivated and uncooperative when, in fact, they want to remember but simply are not able to.”
Again, successful treatment for schizophrenia is comprehensive and includes both pharmacological and psychosocial interventions. Family education is especially critical.
It’s also important to have faith in your loved one and “help them keep hope alive,” Gingerich said. “Focus on their strengths and talents and how they can accomplish their goals and contribute to the world.”
And, if you have schizophrenia, have faith in yourself. “People with schizophrenia can lead productive, rewarding lives.”