Schizophrenia is a chronic condition that resides on a wide spectrum and requires lifelong treatment. Many (mistakenly) think that having schizophrenia is a death sentence. It’s been associated with everything from unemployment to poverty to homelessness.
But this doesn’t have to be you or your loved one’s story.
While schizophrenia can be severe and debilitating, effective treatment absolutely exists. And when individuals stick to treatment, they can lead satisfying and successful lives.
Specifically, medication is the foundation of effective treatment. It helps control the symptoms and psychosis associated with schizophrenia (e.g., the delusions and hallucinations). But medication can’t help with finding a job, sharpening coping skills, and communicating and working well with others. This is where psychosocial and support therapies come in. They’re critical to reducing symptoms and living well.
Medications for Schizophrenia
Medication is the mainstay of schizophrenia treatment. However, one of the biggest challenges with medication is that many people stop taking it. Sometimes, this is because the medication doesn’t seem to be working or the side effects are intolerable.
It’s critical that choosing a medication is a collaborative decision between you and your doctor (and the views of a caregiver may be considered when appropriate). This decision also must include a thorough discussion of potential side effects.
It’s also critical for individuals with schizophrenia to talk with their doctor before stopping or making any changes to their medication. Always voice your concerns. Many side effects can be controlled, and there’s a high risk of symptoms returning after stopping medication. You and your doctor together can figure out an effective solution.
There are two classes of medications that treat schizophrenia. Available since the mid 1950s, traditional or typical antipsychotics primarily block dopamine receptors and effectively control the hallucinations, delusions, and confusion of schizophrenia. They include chlorpromazine, haloperidol, and fluphenazine.
Mild side effects of traditional antipsychotics include: dry mouth, blurred vision, constipation, drowsiness, and dizziness. These side effects usually disappear a few weeks after treatment starts. More serious side effects include: trouble with muscle control, muscle spasms or cramps in the head and neck, fidgeting or pacing, tremors, and shuffling of the feet (much like those affecting people with Parkinson’s disease).
There are also side effects with prolonged use of traditional antipsychotics, such as: facial tics, thrusting and rolling of the tongue, lip licking, panting, and grimacing.
Atypical antipsychotics — which include quetiapine, risperidone, and olanzapine — were introduced in the 1990s. Some of these medications might work on both the serotonin and dopamine receptors, and consequently, might treat “positive” and “negative” symptoms of schizophrenia. Atypical antipsychotics have different side effects than traditional antipsychotics, which include: weight gain, type 2 diabetes, sexual dysfunction, sedation, and irregular heartbeat. Learn more about atypical antipsychotics for treating schizophrenia.
In the past, doctors started individuals on a high dose of a medication, and then possibly reduced it during the maintenance phase of the illness (after an acute episode was successfully treated). However, today, the recommended approach is to start with a lower dose.
Individuals with schizophrenia have the option to take their medication in pill form every day, or to receive a long-acting injectable (LAI). Used with atypical antipsychotic medications, these injections are administered once every few weeks or months (depending on the exact medication prescribed). People with schizophrenia and their caregivers often prefer this option, since it makes taking medication much easier. You can learn more about long-acting treatments for schizophrenia here.
About 25 to 30 percent of people have treatment-resistant schizophrenia. There’s variability in how “treatment resistant” is defined. But it generally means that a person has tried two adequate trials of different antipsychotic medication, and had less than 20 percent reduction in positive symptoms.
According to guidelines in The Canadian Journal of Psychiatry, the only recommended treatment for treatment-resistant schizophrenia is clozapine, the first atypical antipsychotic introduced in the 1970s. The authors note that there’s no consistent evidence to support increasing doses, switching medication, or combining antipsychotic medication. Clozapine also is the only treatment approved by the U.S. Food and Drug Administration for treatment-resistant schizophrenia.
Research has suggested that clozapine is highly effective in reducing suicidality, hospital admissions, aggressive behavior, and tardive dyskinesia (compared to other antipsychotic medications).
Yet, doctors tend to delay in prescribing clozapine—as long as 2 to 5 years in some countries—which has been linked to poorer treatment outcomes. The delay may be due to a lack of experience with prescribing the medication and fear of its potential serious side effects, which include: agranulocytosis, a rare blood disorder characterized by a severe reduction in white blood cells; myocarditis, inflammation of the heart muscle; seizures; and cardiomyopathy, which makes it harder for your heart to pump blood to the rest of your body, and can lead to heart failure.
However, careful monitoring can minimize these side effects. An example is getting weekly blood tests for the first 18 weeks of taking clozapine, every 2 weeks for up to a year, and then monthly thereafter.
Schizophrenia commonly co-occurs with other illnesses. The most prevalent illness is substance use disorder (SUD), with individuals often abusing nicotine, alcohol, cannabis, and cocaine. The first line of treatment with any co-occurring SUD is antipsychotic medication.
UpToDate.com recommends a multimodal, integrated treatment (when available), which includes medication and one or more psychosocial interventions provided by the same clinician or a team. They also recommend a long-acting injectable antipsychotic for individuals who have trouble taking their daily medication and have a SUD.
For individuals who are trying to stop smoking, UpToDate suggests nicotine replacement therapy with a psychosocial treatment as a first-line intervention, instead of medication.
For individuals who have an alcohol use disorder, the FDA-approved medication naltrexone seems to be safe and effective. Higher doses of disulfiram—a medication that creates a very unpleasant reaction when drinking alcohol—has been linked to agitation and worsening of psychotic symptoms.
Psychotherapy plays an important role in the treatment of schizophrenia. For instance, research published in 2015 demonstrated that people who experienced their first episode of psychosis (typically in their 20s) had the best outcomes when a team-based treatment approach was used. The team-based treatment approach incorporated psychotherapy, low doses of antipsychotic medications, family education and support, case management, and work or education support. (You can learn more about the study here.)
In conjunction with a good medication plan, psychotherapy can help a person continue treatment, learn essential social skills, and maintain their weekly goals and activities. It also can help with performing daily activities, such as cooking and personal grooming as well as communicating with loved ones and coworkers. Therapy or rehabilitation therapy can help a person regain the confidence to take care of themselves and live a fuller life.
Group therapy, combined with medication, produces somewhat better results than drug treatment alone. Positive results are more likely to be obtained when group therapy focuses on real-life plans, problems, and relationships; social and work roles and interactions; cooperation with drug therapy and discussion of its side effects; or some practical recreational or work activity. Supportive group therapy can be especially helpful in decreasing social isolation and increasing reality testing.
Family therapy can significantly decrease relapse rates. In high-stress families, individuals with schizophrenia who receive standard aftercare relapse 50-60 percent of the time in the first year out of the hospital. Supportive family therapy can reduce this relapse rate to below 10 percent. Family therapy encourages loved ones to convene a family meeting whenever an issue arises, in order to discuss and specify the exact nature of the problem, to list and consider alternative solutions, and to collaborate on the best solution.
Other treatments are accruing moderate-to-strong research support in treating schizophrenia. For instance, cognitive behavioral therapy (CBT) focuses on testing distressing, strongly held beliefs by examining the evidence for and against them; identifying and achieving life goals; learning coping skills; and improving quality of life.
Acceptance and commitment therapy (ACT), which is based in mindfulness, doesn’t directly aim to reduce psychotic symptoms; rather, ACT aims to reduce a person’s suffering by enhancing their ability to tolerate these symptoms. Individuals are taught to observe psychotic symptoms—such as hearing voices—by being open, curious, accepting, and non-judgmental, instead of being consumed by unhelpful reactions. They also identify their goals and values, and are empowered to create meaningful, satisfying lives.
Another form of evidence-based treatment for schizophrenia, also abbreviated as “ACT” (not to be confused with Acceptance and Commitment Therapy) is assertive community treatment. ACT is a multidisciplinary team approach, typically including case managers, psychiatrists, social workers, and other mental health clinicians. It is an augmentative approach to intensive case management in which the team members share a caseload, see the client at least once a week, and provide outreach to individuals in the community. ACT treatment is typically ongoing and highly individualized to each client’s changing needs. The goals of ACT are to reduce hospitalization rates and help clients adapt to life in the community. ACT is most appropriate for individuals who are at high risk for repeated hospitalizations and have difficulty remaining in traditional mental health treatment.
Cognitive remediation (CR) is intended as a short-term intervention for enhancing cognitive skills required for everyday social/vocational functioning in individuals with schizophrenia (e.g., using computers and handling paper and pencil tasks). Most CR interventions also take into account the motivational and emotional deficits that are highly prevalent in schizophrenia. There is some evidence that these short-term cognitive training therapies can alter neural connections as shown by some studies in neuropsychological testing. It is unclear, however, whether these brain functioning improvements are sustained or translate to functioning.
Similarly, cognitive adaptation treatment (CAT) targets cognitive barriers of schizophrenia that interfere with daily functioning, such as apathy, impulsivity, and trouble taking the mental steps required for problem solving. CAT involves several visits to the person’s home. During these visits, the therapist devises ways to help them compensate for or work around their difficulties. For example, the therapist may rearrange things in your environment, make checklists and reminders, and practice a routine with you.
John M. Grohol, M. (2020). Schizophrenia Treatment. Psych Central. Retrieved on August 8, 2020, from https://psychcentral.com/schizophrenia/schizophrenia-treatment/