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.
Sometimes hospitalization is required to help a person with schizophrenia get stabilized and recover from a psychotic episode. Hospitalization can save lives. Specifically, a person with schizophrenia might be hospitalized when: they have acute symptoms, such as severe delusions or hallucinations, and they’re experiencing a break from reality, and are unable to care for themselves; they’re a danger to themselves or others (e.g., experiencing suicidal thoughts); they need to change or adjust their medication, because it’s no longer working, or has severe side effects; or they’re struggling with substance abuse, or severe symptoms from another mental illness.
In fact, a 2019 study found that having a co-occurring condition—such as substance use disorder, bipolar disorder, or depression—was associated with an increase in the number of hospital stays, and in the length of stay. Also, the more disorders a person was diagnosed with, the greater the number of hospitalizations they experienced.
Sometimes, the person with schizophrenia will realize they’re unwell and go a psychiatric hospital voluntarily. Other times, family members or mental health professionals need to step in and request involuntary commitment. For instance, this might be necessary when a person is having a psychotic episode and believes everyone wants to harm them, including their loved ones.
Every state has different laws for involuntary commitment, but in general, according to Kim T. Mueser, Ph.D, and Susan Gingerich, MSW, in their book The Complete Family Guide to Schizophrenia, the process might look like:
- Individuals petition to have the person with schizophrenia get evaluated by a mental health professional.
- The petition is granted when there’s evidence of the person being a serious danger to themselves or others, and having severe mental illness.
- The person filing the petition usually goes to a community mental health center or a hospital ER.
- Once they’ve completed the petition, a staff member calls the state office of mental health to receive approval.
- If approval is received, and a warrant is issued, the police are called, and they bring the individual with schizophrenia to an emergency facility for the evaluation.
- If the practitioner administering the evaluation determines the person meets criteria for being involuntarily hospitalized, they are committed to treatment for a certain number of days at the closest psychiatric facility with availability.
- At the end of the person’s stay at the hospital, the petitioner appears in court and testifies about the dangerous behavior they witnessed.
- The person with schizophrenia also can testify and have an attorney.
- After considering all the testimony, a judge rules on whether the person should be discharged or remain in the hospital (typically for 2 to 3 weeks).
Most hospital stays are short term—from several days to several weeks. But it really depends on the severity of symptoms, because some people may stay longer.
During their hospital stay, a person will typically get a medical evaluation and attend individual, group, occupational, and recreational therapy.
This information sheet about hospitalization (PDF) provides more information on why someone might need hospitalization, how they can benefit, and what loved ones can do to make the hospital stay as easy as possible, along with hospital experiences from people with schizophrenia and their loved ones.
Coping Guidelines For The Family
If your loved one has schizophrenia, here are some ways you can help.
- Get educated and informed. Learn everything you can about schizophrenia from a variety of resources—self-help books, memoirs, blogs written by people with schizophrenia, podcasts (such as Psych Central’s A Bipolar, a Schizophrenic, and a Podcast). Talk to your loved one about what having schizophrenia is like for them. Talk to them when they’re well about how they’d like to be supported.
- Help your loved one create a daily routine that includes activities that are meaningful to them. When you can, join them. This might be anything from taking a walk to volunteering together.
- Help your loved one take their medication as prescribed, and set up systems that simplify this process. Have an easy-to-use pillbox. Create reminders and alarms. Help them keep track of their symptoms and/or side effects.
- Listen and be empathetic. Keep the lines of communication open about problems, concerns, or fears your loved one might have.
- Devise a plan to deal with episodes. Collaborate with your loved one and their treatment team on a written plan that includes: their individual triggers and warning signs of an episode; tactics for navigating these triggers and signs; healthy tools to turn to; names and numbers of professionals to call; along with other problem-solving strategies and ways to be supportive.
- Help your loved one advocate for themselves. If your loved one doesn’t want to take medication, talk to them about why. Encourage them to be honest with their providers, to voice their concerns, and to collaborate with them on their treatment.
- Commend your loved one’s hard work—and your own (no matter how small it might seem). Here are several examples from the excellent book The Complete Family Guide to Schizophrenia: A parent found it helpful to note something positive every day, such as, “I’m proud of how persistent my daughter has been in pursuing her art career in spite of the many difficulties she’s encountered. We both have a lot to learn about coping with this illness, but we’ve also come a long way.” When one dad’s daughter shared that she felt like a failure for needing to be hospitalized, he told her, “I’m sorry you had to go through that, but I’m proud of you for getting help when you needed it and for being so strong in dealing with this illness. You’re a survivor.”
- Join a support group for family and friends of individuals with schizophrenia. This is a great way to share common experiences and learn strategies to best deal with your frustrations, feelings of helplessness, and sadness. Start your search for a local support group at the National Alliance on Mental Illness.
If you have schizophrenia, there are many things you can do to help and support yourself. Below, you’ll find a short list of ideas.
- Stick to your treatment. Keep attending therapy and taking your medication—and if side effects become intolerable, talk to your doctor before
- Be honest about your thoughts and symptoms. Talk about how you’re feeling with providers and loved ones you trust. If you’re hearing voices or experiencing other hallucinations, let them know.
- Join an in-person or online support group. Having schizophrenia can feel incredibly isolating—until you realize that you’re not alone, and even though everyone’s specific experiences are different, there are many, many commonalities. In addition to the connection, support groups are an invaluable place to pick up helpful coping tools and strategies.
- Minimize stress. Stress can exacerbate symptoms and trigger an episode. Along with your treatment team, identify what people, places, and situations are stressful for you, and the various ways you can effectively navigate those stressors.
- Have a solid plan for difficult times. As mentioned earlier (in the section on coping tips for family and friends), plan ahead on how to deal with challenging times, episodes, and crises. When you create this plan when you’re well, you make it much easier to help you when you aren’t.
- Find healthy ways to deal with hearing voices (if you do). The key in getting better isn’t to stop hearing the voices; it’s to learn to effectively interpret and interact with them. The British mental health charity Mind has helpful information on managing your voices. This Ted talk from Eleanor Longden, who has schizophrenia, also provides a valuable perspective.
- Set goals. You can absolutely live a meaningful, enjoyable life with schizophrenia. Think about what you want and what you value. Then, together with your treatment team and/or a loved one, brainstorm small steps you can take to make this happen.
- Fill your days with fulfilling activities. What do you love to do? What are your favorite hobbies? Maybe it’s writing or gardening or painting or running outside. Carve out time to engage in these activities on a daily or weekly basis. Again, schizophrenia is a difficult disorder, but it doesn’t have to shatter your life.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Beck, A.T., Rector, N.A., Stolar, N. & Grant, P. (2011). Schizophrenia: Cognitive Theory, Research, and Therapy. New York: Guilford Press.
Campbell, C.E., Caroff, S.N., Mann, S.C. (2018). Pharmacotherapy for co-occurring schizophrenia and substance use disorder. UpToDate. Retrieved from https://www.uptodate.com/contents/pharmacotherapy-for-co-occurring-schizophrenia-and-substance-use-disorder
Healthwise. (2019). Schizophrenia: When Hospital Care is Needed. Retrieved from https://www.healthlinkbc.ca/health-topics/ug5101
Janicak, P.G., Marder, S.R., Tandon, R., Goldman, M. (2014). Schizophrenia Recent Advances in Diagnosis and Treatment. New York: Springer.
Kar, N., Barreto, S., Chandavarkar, R. (2016). Clozapine monitoring in clinical practice: Beyond the mandatory requirement. Clinical Psychopharmacology and Neuroscience, 14, 4, 323-329.
Kessler, T., Lev-Ran S. (2019) The association between comorbid psychiatric diagnoses and hospitalization-related factors among individuals with schizophrenia. Comprehensive Psychiatry, 89, 7-15.
Little, J. (2017). Lived experience tips for managing schizophrenia. SANE Australia. Retrieved from https://www.sane.org/the-sane-blog/managing-symptoms/lived-experience-tips-for-managing-schizophrenia
Louise, S., Fitzpatrick, M., Strauss, C., Rossell, S.L., Thomas, N. (2018). Mindfulness-and acceptance-based interventions for psychosis: Our current understanding and a meta-analysis. Schizophrenia Research, 192, 57-63.
Mueser, K.T. & Gingerich, S. (2006). The Complete Family Guide to Schizophrenia: Helping Your Loved One Get the Most Out of Life. New York: Guilford Press.
National Institute of Mental Health. (2018). Schizophrenia. Retrieved from https://www.nimh.nih.gov/health/publications/schizophrenia/index.shtml.
Olukayode, A. et al. (2014). The 4th Schizophrenia International Research Society Conference, 14-18 April 2014, Florence, Italy: A summary of topics and trends. Schizophrenia Research, 159, e1-22.
Rado, J. & Janicak, P.G. (2016). Living with Schizophrenia: A Family Guide to Making a Difference. Johns Hopkins Press Health Book.
Remington, G., Addington, D., Honer, W., Ismail, Z., Raedler, T., Teehan, M. (2017). Guidelines for the pharmacotherapy of schizophrenia in adults. The Canadian Journal of Psychiatry, 62, 9, 604-616.
Shah, P., Iwata, Y., Plitman, E., Brown, E.E., Caravaggio, F., Kim, J., Nakajima, S., Hahn, M., Remington, G., Gerretsen, P., Graff-Guerrero, A. The impact of delay in clozapine initiation on treatment outcomes in patients with treatment-resistant schizophrenia: A systematic review. Psychiatry Research, 286, 114-122.