2. WHAT IS SCHIZOPHRENIA ?
• The schizophrenic disorders are characterized in general by
fundamental and characteristic distortions of thinking and
perception, and by inappropriate or blunted affect.
• Clear consciousness and intellectual capacity are usually
maintained, although certain cognitive deficits may evolve in
the course of time.
3. WHAT IS SCHIZOPHRENIA ?
• Schizophrenia encompasses:
Positive Symptoms – Hallucinations & Delusions
Negative Symptoms – Lack of motivation , poverty of
speech
Cognitive Deficits – Impairment in attention , memory
and problem solving
Psychosocial obstacles – Poor or lacking social
relationships , unemployment , high risk of substance
abuse , increased risk of homelessness , strain in family
relations
5. PHASES OF TREATMENT IN
SCHIZOPHRENIA
• ACUTE PHASE - characterized by psychotic symptoms that
require immediate clinical attention.
Treatment during this phase focuses on alleviating the most
severe psychotic symptoms.
Usually last from 4 to 8 weeks.
Acute schizophrenia is typically associated with severe
agitation, which can result from such symptoms as frightening
delusions ,hallucinations or suspiciousness or from other
causes ,including stimulant abuse.
6. • STABLIZATION PHASE:
In which acute symptoms have been controlled ,but patients
remain at risk for relapse if treatment is interrupted or if the
patients are exposed to stress.
During this phase, treatment focuses on consolidating
therapeutic gains, with similar treatments as those used in the
acute stage.
This phase last as long as 6 months following recovery from
acute symptoms.
• STABLE OR MAINTANENCE PHASE-
When illness is either in a relative stage of remission or
symptomatically stable.
Goals during this phase are to prevent psychotic relapse or
exacerbations and to assist patients in improving their level of
functioning.
7. REASON FOR HOSPITALIZATION
INDICATED FOR:
• For Diagnostic purposes
• For Stabilization of medications
• For patients /relatives safety(suicidal and homicidal ideation)
• For grossly disorganized or inappropriate behaviour
(including the inability to take care of basic needs such as food ,
clothing and shelter)
Hospital treatment plans should be oriented towards practical
issues of self –care , quality of life ,employment and social
relationships
8. ASSESSMENT
• Before starting medication patients should receive a physical
examination with neurological examination ,a mental status
examination, and a laboratory evaluation.
• Blood tests for complete blood count (CBC),electrolytes ,
fasting glucose , lipid profile , liver , renal , and thyroid
function should be ordered.
• Other evaluations that should be considered are pregnancy
test in women, and hiv test.
• Individuals with schizophrenia are at a higher risk for
cardiovascular disease than the population at large.
9. • RATING SCALES USED FOR ASSESMENT OF SYMPTOMS OF
SCIZOPHRENIA: Should be applied at baseline.
• Following scales can be used:
PANSS (Positive and negative symptoms scale)
SANS(Scale for the assessment of negative symptoms)
SAPS(scale for assessment of positive symptoms)
BPRS(brief psychiatric rating scale)
10. • Treatment of schizophrenia:
Pharmacological
Non pharmacological
Combined
11. • Antipsychotic medications-the mainstay of pharmacological
treatment –are effective for reducing the impact of psychotic
symptoms such as hallucinations, delusions and
suspiciousness.
• In many symptoms can be completely eliminated , once these
symptoms are minimized , medications can decrease the
likelihood that symptoms will recur.
12. SELECTION OF AN ANTIPSYCHOTIC
DRUG
Antipsychotics are categorized into two main groups
1st generation (FGAs) 2nd generation(SGAs)or
dopamine receptor antagonists(DAs) serotonin dopamine antagonist (SDAs)
• FGAs are further categorized as being low, mid or high potency.
• Higher potency drugs – more specificity and greater affinity for D2
receptor and greater tendency to cause EPS.
• Lower potency drugs are less likely to cause EPS, but likely to cause
hypotension, sedation, and anticholinergic effects.
• Basically selection of drug is based on individual patient profile.
13. • SELECTION OF DRUGS DEPENDS ON:
Availability
Side effect profile
Symptoms
Specifics contraindications
Familiarity
Cost
14. COMPARISONS OF ANTIPSYCHOTICS
• CUtLASS (cost utility of latest antipsychotic drugs in
schizophrenia) and
• CATIE ( clinical antipsychotic trial of intervention effectiveness)
both studies did not found substantial advantages in overall
tolerability , acceptability, and effectiveness for SGAs over FGAs.
18. Either ;
Agree choice of antipsychotic with patient
Or, If not possible;
Start 2nd generation antipsychotic
Titrate , if necessary , to minimum affective dose
Adjust dose according to response and tolerability
Assess over 2-3 weeks
19. Change drug and
follow above process
consider use of either
a SGAs or a FGAs
If poor compliance related to
poor tolerability, discuss with
pt and change the drug.
If poor compliance related to
other factors, consider early
use of depot.
Continue at dose
established as effective
Clozapine
(THE MAUDSLEY,PRESCRIBING GUIDELINES IN PSYCHIATRY,12TH EDITION)
20. TREATMENT OF RELAPSE OR
ACUTE EXACERBATIONS
(Full adherence to medication confirmed)
21. Investigate social or psychological precipitants
Provide appropriate support and or therapy.
Continue usual drug treatment
Add-short term sedative
Or
Switch to different, acceptable discuss choice with pts
and assess over at least 6 weeks
Switch to clozapine
(THE MAUDSLEY,PRESCRIBING GUIDELINES IN PSYCHIATRY,12TH EDITION)
22. TREATMENT OF RELAPSE OR ACUTE
EXACERBATIONS
(ADHERENCE DOUBTFUL OR KNOWN TO BE POOR)
23. • Confused or
• disorganised
Lack of insight poorly
tolerated t/t
Or support
Investigate reasons for poor
adherence
Simply drug regimen
Reduce anticholinergic
load
Consider depot
Discuss with the patient
consider depot antipsychotics
Discuss with patient switch to
acceptable drug
24. • First generation drugs may be slightly less efficacious than some
SGAs. FGAs should be probably be reserved for 2nd line use
because of the possibility of poorer outcome compared with
FGAs and higher risk of movement disorder ,particularly tardive
dyskinesia.
• Choice is, however, based largely on comparative adverse effect
profile and relative toxicity. patients seem able to make
informed choices based on these factors, although in practice
they may only very rarely be involved in drug choice.
• Where there is prior treatment failure olanzapine or risperidone
may be better options than quetiapine.
• Olanzapine because of the wealth of evidence suggesting slight
superiority over other antipsychotics , should always be tried
before clozapine unless contraindicated.
• Where there is confirmed treatment resistance evidence
supporting the use of clozapine is overwhelming.
25. MANAGING AGITATIONIN ACUTEPSYCHOSIS
• Agitation in acute schizophrenia can result from disturbing
psychotic symptoms such as frightening delusions or
suspiciousness or from other including stimulants abuse or EPS,
particularly akathisia.
• If pts are receiving agent associated with EPS, usually a first
generation , a trial with anticholinergic anti-parkinsonism
medication or propranolol may be helpful in making the
discrimination.
• An advantage of an antipsychotic is that a single i.m injection of
haloperidol, fluphenazine ,olanzapine , aripiprazole or ziprasidone
will often result in calming without an excess of sedation.
26. • Intramuscular ziprasidone, aripiprazole , and olanzapine are
similar to their counterparts in not causing substantial EPS
during acute treatment.
• Rapidly dissolving oral olanzapine, risperidone or aripiprazole
may also be helpful as an alternative to an intramuscular
injection.
• Benzodiazapines are also effective for agitation during
psychosis.
• Lorazepam has the advantage of reliable absorption when
administered either orally or intramuscularly.
• The combination of lorazepam + antipsychotic found safer
and more effective than large doses of DAs in controlling
excitement and motor agitation.
27. ACUTEMANGEMENTOFPSYCHOTICEPISODE
• With exception of Canadian guidelines ,all other recommend
the use of either SGAs (1st line) or FGAs (2nd line) as standard
drugs.
• The Canadian guidelines only recommend the use of SGAs
such as olanzapine , risperidone or quetiapine.
• Based on recent evidence, the unified guidelines
recommends the use of either 1st or 2nd generation
antipsychotics based on clinical and economic needs at a
dosage of 300-1000 chlorpromazine equivalents.
28. PROPHYLAXIS OF SCHIZOPHRENIA
• All guidelines recommend the continued use of the same
antipsychotic used to manage the acute episode for prophylaxis.
• In longer term a balance needs to be made between
effectiveness and adverse-effects.
• Very low doses increase the risk of psychotic relapse.
29. HOW AND WHEN TO STOP?
• Decision to stop antipsychotic drugs require a through risk-
benefit analysis for each pt.
• Withdrawal of drug after long term t/t should be gradual and
closely monitored.
• The relapse rate in 1st 6months after abrupt withdrawal is
double that seen after gradual withdrawal (slow taper down
over at least 3wks for oral antipsychotics or abrupt stopping of
depot preparation)
30. DURATION OF PHARMACOTHERAPY
• The APA and Canadian guidelines recommended similar
duration of acute( , stabilization ,and stable phase treatment.
• The NICE and Maudsley guidelines recommend acute
treatment to last 2 years and give no specific
recommendation on duration of prophylaxis.
• The unified guidelines recommends:
The acute phase treatment : last at least 12 weeks,
The stabilization phase :last at least 12 months,
The stable phase : last at least 2 years for a first episode and
5 years to lifetime for multiple episodes.
31. NON-PHARMACOLOGICALTREATMENT
• Often pharmacotherapy alone is not enough to address the
devastating functional consequences of this condition and
most individuals with schizophrenia continue to experience
significant social, functional, and vocational disability leading
to a poor quality of life.
• This highlights the critical importance of the use of
psychosocial interventions to help further the recovery of
people with schizophrenia.
32. The Schizophrenia Patient Outcomes Research Team (PORT) provide
recommendations on current evidence-based psychosocial treatment
interventions for persons with schizophrenia.
2009 PORT review produced psychosocial treatment recommendations:
1. Family-based services,
2. Token economy,
3. Skills training
4. Assertive community treatment,
5. Supported employment,
6. Cognitive behavioural therapy,
33. SOCIAL SKILL TRAINING
• Persons with schizophrenia who have skill deficits such as
problems with social skills or activities of daily living should be
offered skills training.
• In addition to psychotic symptoms seen in patient with
schizophrenia , other noticeable symptoms involve:
The way person relate to others
Including poor eye contact
Unusual delay in response
Odd facial expressions
Lack of spontaneity in social situations etc.
34. • Behavioural skills training addresses these behaviours through
the use of video tapes of others and of the pt, role playing,
home work assignments for specific skills being practiced.
• Social skill training has been shown to reduce relapse rates as
measured by the need for hospitalization.
35. TOKEN ECONOMY INTERVENTIONS
• A token economy is a system of behavior modification based on the
principles of operant conditioning.
• Emphasis is on reinforcing positive behaviour by awarding "tokens"
for meeting positive behavioural goals.
• Patients earn tokens, which they can exchange for privileges, such as
time watching television or walks on the hospital grounds, by
completing assigned duties (such as making their beds) or even just
by engaging in appropriate conversations with others
36. • Advantages of token economy
• tokens are flexible
• tokens can be used for several needs and therefore saturation is
improbable
• there is no delay giving tokens after the desired behavior has been
shown
• mostly the token economy is well-regulated thus it is easy for
therapists to decide whether they have to give a token or not
37. FAMILY INTERVENTIONS
• PORT Recommendation. Persons with schizophrenia who have on-
going contact with their families, including relatives and significant
others, should be offered a family intervention that lasts at least 6–9
months.
• ‘Family’ includes people who have a significant emotional connection
to the service user, such as parents, siblings and partners.
• The goals of family-based services are
to increase understanding of the disorder,
reduce levels of expressed emotion,
reduce feelings of isolation, stress, and burden of family members,
foster development of coping skills, and
develop an ongoing collaborative relationship between family and
clinicians.
38. AIMS OF FAMILY INTERVENTIONS:
To help families cope with their relatives’ problems more
effectively.
Collaboration with relatives who care for the person with
schizophrenia.
Reducing the emotional stress and burden on relatives and
within the family unit.
Enhancement of relatives' ability to anticipate and solve
problems.
Reducing expressions of anger and guilt by the family .
Maintenance of reasonable expectations for patient
performance
Attainment of desirable change in relatives' behavior and belief
system
39. FAMILY INTERVENTIONS
This can be started either during the acute phase or later,
including in inpatient settings.
Family intervention should:
• include the person with schizophrenia if practical.
• be carried out for between 3 months and 1 year
• include at least ten planned sessions
• take account of the whole family’s preference for either
single-family intervention or multi-family group intervention
• take account of the relationship between the main carer and
the person with schizophrenia
• have a specific supportive, educational or treatment
function and include negotiated problem solving or crisis
management work.
40. FAMILY INTERVENTIONS
• For whom a longer intervention is not feasible or acceptable
a shorter intervention that is at least 4 sessions in length
should be offered to persons with schizophrenia.
• Characteristics of the briefer interventions include education,
training, and support.
• Proposed as adjuncts rather than alternatives to drug
treatments
• The selection of a family intervention should be guided by
collaborative decision making among the patient, family,
and clinician.
41. Family interventions have been found to significantly reduce
rates of relapse and re-hospitalization
Possible benefits for patients include :
• reduced psychiatric symptoms,
• improved treatment adherence,
• improved functional and vocational status, and
• greater satisfaction with treatment.
Positive family outcomes include :
• reduced family burden and
• increased satisfaction with family relationships.
42. PSYCHOEDUCATION
Implies provision of information and education to a service user
with a severe and enduring mental illness, including
schizophrenia, about the diagnosis, its treatment, appropriate
resources, prognosis, common coping strategies and rights.
Psychoeducation involves quite lengthy treatment and runs into
management strategies, coping techniques and role-playing skills.
It is commonly offered in a group format.
Psychoeducational interventions were defined as:
• any programme involving interaction between an
information provider and service users or their carers, which
has the primary aim of offering information about the
condition; and
• the provision of support and management strategies to service
users and carers.
To be considered as well defined, the educational strategy should
be tailored to the need of individuals or carers.
43. ASSERTIVECOMMUNITYTREATMENT
PORT Recommendation: Systems of care serving persons with schizophrenia
should include a program of assertive community treatment (ACT).
It should be provided to individuals who are at risk for repeated
hospitalizations or have recent homelessness.
The key elements of ACT include
• A multidisciplinary team including a medication prescriber,
• A shared caseload among team members,
• Direct service provision by team members,
• A high frequency of patient contact,
• Low patient-to-staff ratios (usually 10–15 patients per member), and
• Outreach to patients in the community.
44. • In ACT patients are diverted to the care of a community-based,
multidisciplinary team including psychiatrists, nurses, and social workers.
• The team carries small case loads and sees patients frequently in their own
homes or in the workplace and deliver all services when and where needed
by the pateint,24hrs a day,7 days a week.
• This mobile and intensive intervention that provides treatment ,
rehabilitation and support activities.
• These include home delivery of medications, monitoring of mental and
physical health, in vivo social skills and frequent contact with the family
members.
• There is high staff-to-patient ratio (1:12) ACT programs can effectively
decrease the risk of hospitalization for persons with schizophrenia , but they
are labor-intensive and expensive programs to administer.
45. • Teams care for the full range of acutely ill patients, including those
who are suicidal, potentially violent or reluctant service users.
• ACT teams also place particular emphasis on medication adherence
• ACT has the same aims as case management but whereas under case
management great emphasis is placed on individual responsibility of
case managers for clients, ACT by contrast emphasizes team-working.
• Care is provided at, as far as possible.
• ACT has been found to significantly reduce hospitalizations and
homelessness among individuals with schizophrenia.
46. COGNITIVE BEHAVIOUR THERAPY
• Persons with schizophrenia who have residual psychotic
symptoms while receiving adequate pharmacotherapy should
be offered adjunctive cognitive behaviourally oriented
psychotherapy .
• The key elements of this intervention include:
A shared understanding of the illness between the patient and
the therapist.
The identification of target symptoms.
The development of specific cognitive and behavioural
strategies to cope with these symptoms.
47. COGNITIVE BEHAVIOUR INTERVENTIONS
• There is evidence for the effectiveness of CBT in the treatment
of several forms of psychopathology, including anxiety and
affective disorders.
• Controlled studies have shown benefits of CBT in reducing the
severity of delusions, hallucinations, positive symptoms,
negative symptoms, and overall symptoms and in improving
social functioning among individuals with schizophrenia who
have persistent psychotic symptoms despite adequate
pharmacotherapy
48. COGNITIVE BEHAVIORAL THERAPY
CBT focuses on :
Helping individuals recognize delusional thoughts and
testing of key beliefs that may be supporting delusional
thinking
Helping in recognizing early signs of relapse and
development of problem-solving strategies to reduce
relapse.
learning and strengthening skills for coping with and
reducing symptoms and stress.
Identification of factors exacerbating symptoms.
development of a collaborative understanding of the
nature of the illness, which encourages the patient’s
active involvement in treatment
49. VOCATIONAL REHABILITATION
• Employment rates among individuals with schizophrenia and
related disorders are substantially lower than in the general
population.
• Employment status appears likely to have substantial impact on
the economic circumstances of many patients and influences many
aspects of quality of life.
• Two main classes of programes have evolved to help people stay in
employment:
• pre-vocational training
• supported employment
• There is no evidence that employment obtained with these
methods leads to increased stress or exacerbation of symptoms
• There is some, evidence that employment status may have positive
impacts on self-esteem, on aspects of psychiatric symptoms, and
on the likelihood of relapse.
50. • In Prevocational training participants undergo a period of
extensive preparation before being encouraged to seek
competitive employment. The person is supported in some form of
sheltered work before entering real-world employment
• In Supported employment the emphasis is on placing individuals in
competitive employment sooner and offering considerable after-
placement job-support services from a team of professionals.
• There is strong evidence that supported employment is
superior to prevocational training, improving employment
prospects and hours per week spent in competitive employment
significantly more when the two are compared.(NICE 2010)
52. APA CANADIAN NICE MAUDSLEY
ACUTE T/T OF 1ST
EPISODE
SGAs/FGAs Olanzapine
Risperidone
Quetiapine
SGAs/FGAs SGAs/FGAs
PROPHYLAXIS To continue same
antipsychotic
To continue
same
antipsychotic
To continue
same
antipsychotic
To continue
same
antipsychotic
DURATION ACUTE:
4 TO 8 wks.
STABILIZATION: upto
6 months.
STABLE :upto 1 to
1.5yrs in 1st episode;
5 to 10 yrs in case of
2 or more episode &
indefinite for
multiple prior
episodes or more
than 2 episodes in
5yrs.
ACUTE PHASE:
6 to 12 wks
STABILIZATION
PHASE:
1 Yr
STABLE PHASE:
upto 2 yrs in 1st
episode and
upto 5yrs in
case of multiple
episodes.
Acute treatment
to last 2yrs .
No duration of
long term
treatment
indicated
Same as NICE
53. APA CANADIAN NICE MAUDSLEY
PSYCHOSOCIAL
MANAGEMENT
Family psycho-
education
(>9 months),
Assertive
community
treatment,
supported
employment,
social skills
training and CBT
( 16-20 sessions)
Supported
employment,
family psycho-
education,
skills training,
and CBT
CBT(16-sessions)/
FFT(10 sessions)/
arts therapy/
supported
employment
No
recommendati
ons
54. REFERENCES
• Kaplan and Sadock’s Comprehensive textbook of psychiatry,9th
edition,Volume 1 Chapter 12,pg 1645-1652 and pg 1693-
1733.
• Kaplan and Sadock’s Synopsis of Psychiatry Behavioral
Sciences/Clinical Psychiatry,11th edition,chapter 13,pg.no 488-
497.
• The Maudsley prescribing guidelines in psychiatry, 12th
edition,chapter 2 ,pg. no 15-77.
• American Psychiatric Association. Practice Guideline for the
Treatment of Patients With Schizophrenia.
55. • Robert w. buchanan et al,the schizophrenia port
psychopharmacological treatment recommendations and
summary statements, schizophr bull.2010 jan;36(1):71-93.
• S.saddichha and santosh k. chaturvedi,Clinical practice
guidelines in psychiatry: more confusion than clarity? A critical
review and recommendation of a unified guideline.ISRN
psychiatry,vol.2014.
56.
57.
58. APA CANADIAN NICE MAUDSLEY UNIFIED
PSYCHOSOCIAL
MANAGEMENT
Family psycho-
education
(>9 months),
Assertive
community
treatment,
supported
employment,
social skills
training and
CBT ( 16-20
sessions)
Supported
employment
, family
psycho-
education,
skills
training, and
CBT
CBT(16-
sessions)/
FFT(10
sessions)/
arts therapy/
supported
employment
No
recommen
dations
Family psycho-
education
(>9months)
Assertive
community
treatment,
supported
employment,
social skill
training and
CBT( 16-20
sessions)
59. APA CANADIAN NICE MAUDSLEY UNIFIED
ACUTE T/T OF
1ST EPISODE
SGAs/FGAs Olanzapine
Risperidone
Quetiapine
SGAs/FGAs SGAs/FGAs SGAs/FGAs
PROPHYLAXIS To continue
same
antipsychotic
To continue
same
antipsychotic
To continue
same
antipsychotic
To continue
same
antipsychotic
To continue
same
antipsychotic
DURATION ACUTE:
4 TO 8 wks.
STABILIZATION:
upto 6 months.
STABLE :upto 1
to 1.5yrs in 1st
episode;
5 to 10 yrs in
case of 2 or
more episode &
indefinite for
multiple prior
episodes or
more than 2
episodes in 5yrs.
ACUTE
PHASE:6 to
12 wks
STABILIZATIO
N PHASE:
1 Yr
STABLE
PHASE: upto
2 yrs in 1st
episode and
upto 5yrs in
case of
multiple
episodes.
Acute
treatment to
last 2yrs .
No duration
of long term
treatment
indicated
Same as NICE ACUTE
PHASE: upto
12 wks
STABILIZATIO
N
PHASE:upto
12 months
STABLE
PHASE:
2yrs for 1st
and 5 yrs to
life time for
subsequent
episodes.
