Discuss the Main Treatments for Schizophrenia
Treatments for Schizophrenia
The use of drugs or psychotherapies can be used in order to treat schizophrenia. If the causes of schizophrenia are physiological then it follows that treatments should be physiological. However it has been shown that both physiological and psychological factors can lead to the condition of schizophrenia, so it makes sense to consider both forms of treatment. Physiological treatments appear to fail not because they are ineffective but because patients often dislike the side effects of drugs and therefore don’t take them. As a result, psychological treatments (psychotherapies) are frequently used as an alternative to physiological treatments, or in addition to them.
Chemotherapy- Anti Psychotic Drugs
There are two main categories of drugs-
- Conventional Neuroleptic Drugs/ Anti Psychotic Drugs
- Newer Atypical Drugs
Conventional Anti Psychotic Drugs (such as Thorazine, Prolixin, Haldol and Chlorpromazine)
Conventional anti psychotic drugs are used to combat the positive symptoms such as hallucinations and thought disturbances. The positive symptoms are thought to be products of an overactive dopamine system. Conventional antipsychotics reduce dopamine levels. They are dopamine antagonists in that they bind to, but do not stimulate dopamine receptors, therefore blocking their action. In other words, they block the activity of the neurotransmitter dopamine, and this happens within 24 hours of taking the drug. However, it can actually take several weeks of drug therapy before schizophrenic symptoms show substantial reduction.
But do they really work?
COMER (2000) argues that neuroleptics reduces schizophrenic symptoms in the majority of patients and appear to be more effective treatment for schizophrenia than any of the other approaches alone. He also suggests that neuroleptics tend to have their strongest benefit in the first 6 months. However even though COMER suggested that they were the most effective treatment it has been shown that there can be serious problems if patients with schizophrenia stop taking the drugs at any point, even after several years.
DAVIS ET AL. (1980) also researched into the effectiveness of antipsychotic drugs. They analysed the results of 29 studies (meta-analysis which included 3519 people in total) and found that relapse occurred in 55% of the patients whose drugs were replaced by a placebo, but relapses was significantly less (19%) in those who remained on the drug. However, ROSS & READ (2004) point out that these figures are misleading, because they also show that 45% of those who were given a placebo had no relapse, i.e. a significant number did just as well with the placebo therapy.
The advantages of meta-analysis include more reliable conclusions to be drawn, studies often produce rather contradictory results, for example some studies may find no effects, and some studies may find small effects while other studies find a larger effect. Therefore a meta-analysis allows us to reach and overall conclusion. On the flip side the disadvantage is the research designs in the different studies sampled may vary considerably which means that the studies are not truly comparable and therefore the conclusions may not always be valid.
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Also, on a negative side of the treatment as stated above, neuroleptic drugs do have side effects.
WINDGASSEN (1992) found that 50% of patients reported grogginess or sedation, 18% reported problems with concentration and 16% had blurred vision. In addition, many patients develop symptoms closely resembling Parkinson’s disease (e.g. muscle rigidity, tremors and foot shuffling). Approximately 2% of patients (mainly elderly ones) develop neuroleptic malignant syndrome (muscle rigidity, altered consciousness, fever, fatality). Drug treatment is halted as soon as the development of the condition is suspected. Most side effects occur within a few weeks of the start of the therapy but 20% of patients develop tardive dyskinesia after a year. Symptoms include involuntary sucking and chewing, jerky movements of the limbs and writhing movements of the mouth and face. These effects can be permanent. The greater the symptoms the higher the dosages of the drug being used, therefore it is a difficult juggling act to maximise the beneficial effects of treating schizophrenia while trying to avoid as many side effects as possible.
Newer Atypical Anti Psychotic Drugs (such as clozapine, Risperdal, Zyprexa)
Atypical drugs also combat the positive symptoms, but may have some beneficial effects on negative symptoms as well. They are thought to act on both dopamine and serotonin levels, though there isn’t universal agreement on this. KAPUR & REMINGTON (2001) suggest that they act on D₂ receptors alone and only occupy the receptors temporarily and then rapidly dissociate to allow dopamine transmission. It is this characteristic of atypical antipsychotics that is thought to be responsible for the lower level of side effects found with these drugs compared with conventional antipsychotics. They are thought to be as effective as traditional drugs but have fewer side effects. For example, JESTE ET AL. (1999) found tardive dyskinesia rates after 9 months of treatment of 30% for conventional antipsychotics but just 5% for atypical antipsychotics. This means that atypical antipsychotics may ultimately be more appropriate because they have fewer side effects, which in turn means that patients are more likely to continue their medications and therefore see more benefits.
Atypical versus Conventional Antipsychotics-
Although the introduction of the new ‘atypical’ antipsychotics raised expectations for the outcomes possible with medication, a meta-analysis of studies revealed that the superiority of these drugs compared with conventional antipsychotics was only moderate (LEUCH ET AL. (1999)). This analysis found that two of the new drugs tested were only ‘slightly’ more effective that conventional antipsychotics, while the other two were no more effective.
Drugs may block the search for psychological solutions-
ROSS & READ (2004) argue that being prescribed medication reinforces the view that there is ‘something wrong with you’. This prevents the individual from looking for, and dealing with, possible stressors (such as life history or current circumstances) that might be responsible for their condition in the first place.
Drugs can be argued to be a ‘useful’ treatment as schizophrenia has been seen to have a strong genetic and biological basis so drug therapy can be assumed to be appropriate, however this can also be seen as being a determinist approach to the treatment of schizophrenia, forgetting to look in depth at the psychological and cognitive reasons/treatments of schizophrenia.
However, drug therapy has been shown to often reduce systems of schizophrenia more rapidly than psychological therapies, and it may also allow patients to live relatively normal lives (prior to drug therapy, many patients were restrained in hospitals). On the other hand there are major downsides to the use of drugs as a treatment for schizophrenia, these include: that drug therapy is basically palliative treatment as it only suppresses symptoms rather than addressing and reducing or eliminating the underlying processes responsible for causing the disorder, therefore drugs/chemotherapy can be a reductionist approach. Also some patients may be resistant to drugs so drugs are not effective with everyone although those who do not respond to traditional drugs often respond to atypical ones. Finally, there is a huge battle with getting the correct dosage for an individual as high doses produce side effects however low doses reduce side effects but also make the drugs less effective towards the treatment of schizophrenia. There is also a problem with compliance; patients are often reluctant to take drugs (or continue taking them) because of the side effects which can lead to tragic results in some cases, since they do not ‘cure’ schizophrenia, drugs will have to be continued intermittently for life which in itself has issues due to the increased likelihood of disabling side effects with long term treatment.
Cognitive Behavioural Therapy (CBT)
CBT is now the most commonly used form of psychological therapy. CBT therapists assume that people with schizophrenia have irrational thoughts and beliefs about themselves and about the world around them. These beliefs are typically negative and self-defeating. The central goal of CBT is to eliminate irrational thoughts and beliefs by challenging them. For example, someone with schizophrenia may believe that their behaviour is being controlled by someone or something else, so CBT is used to help the patient to identify and correct these faulty interpretations.
The learning of maladaptive responses to life’s problems is often the result of distorted thinking by the schizophrenic, or mistakes in assessing cause and effect (for example, assuming that something terrible has happened because they wished it). During CBT, the therapist lets the patient develop their own alternatives to these previous maladaptive beliefs, ideally by looking for alternative explanations and coping strategies that are already present in the patients mind.
It used to be thought that schizophrenia was such a serious mental health disorder that it would be a waste of time talking to patients and persuading them to modify their irrational thoughts. However, the success of drug therapy means that patients can be more responsive to CBT. Also, it has been found that patients with schizophrenia do actively engage in coping strategies to control their delusions and hallucinations.
CBT Techniques- CBT usually takes place weekly or fortnightly for between five and twenty sessions. Patients are encouraged to trace back the origins of their symptoms in order to get a better idea of how they might have developed schizophrenia. Understanding where symptoms originate can be crucial for some patients. For example, if a patient hears voices and believes they are demons, they will naturally be very afraid. Offering a range of psychological explanations for the existence of hallucinations and delusions can help reduce this anxiety. Patients are also encouraged to evaluate the content of their delusions or of any voices and to consider ways in which they might test the validity of their faulty beliefs. Patients might also be set behavioural assignments which can enable them to improve their general level of functioning. A therapist may draw diagrams for patients to show them the links between their thinking, behaviour and emotions.
CBT cannot completely eliminate the symptoms or ‘cure’ schizophrenia but it can make patients better able to cope with their maladaptive behaviours.
Surprisingly, TARRIER (1987) found that 75% of patients experiencing delusions and/or hallucinations reported using coping strategies already, suggesting that therefore CBT is a good tool to relieve symptoms of schizophrenia. Some coping strategies included; the use of distraction, concentrating on a particular task and positive self talk. About one-third of these used behavioural strategies too such as turning the TV up to drown out voices. And also, 72% of these patients using strategies reported that at least one of their strategies was successful in controlling their symptoms.
CBT focuses primarily on the positive symptoms of delusions and hallucinations (it is rarely designed to reduce negative symptoms).
One approach is the COPING STRATEGY ENHANCEMENT-
Initially the therapist asks detailed questions to establish the content of the delusions and hallucinations, the triggers for these thoughts, and the coping strategies they use. Patients then rate their coping strategies in terms of effectiveness. One delusion or hallucination is selected for treatment (often one for which the patient already possesses moderately effective coping strategies for). The therapist and patient try to identify additional coping strategies and the patient is given homework of applying one or more coping strategy whenever the target delusion or hallucination is experienced. Once the strategies have been tried out, the therapist and patient will discuss ways of making them more effective.
Other forms of CBT include reality testing where the therapist and patient plan an activity that is designed to test the validity of a delusional belief.
Effectiveness of cognitive behavioural therapy- Outcome studies measure how well a patient does after a particular treatment, compared with accepted form of treatment for that condition. Outcome studies of CBT suggest that patients who receive such treatment experience fewer hallucinations and delusions and recover their functioning to a greater extent than those who receive antipsychotic medication alone. DURY ET AL. (1996) found benefits in terms of a reduction of positive symptoms and a 25-50% reduction in recovery time with patients given a combination of antipsychotic medication and CBT. This may be because medication allows access to the benefits of CBT.
But how effective is CBT alone? A study by KULPERS ET AL. (1997) confirmed the effectiveness of CBT but also noted that there were lower patient drop-out rates and greater patient satisfaction when CBT was used in addition to antipsychotic drugs. In fact, the majority of studies looking into the effectiveness of CBT have been conducted with patients treated at the same time with antipsychotic medication. It is therefore very difficult to assess the effectiveness of CBT independent of antipsychotic medication.
Appropriateness of CBT- It is commonly believed within psychiatry that not everyone with schizophrenia may benefit from CBT. In a study of 142 schizophrenic patients, KINGDON & KIRSCHEN (2006) found that many patients were not deemed suitable for CBT because psychiatrists believed they would not fully engage with the therapy. In particular they found that older patients were deemed less suitable than younger patients. This leaves some questioning around age bias and treatment.
However, on the other hand CBT can be argued to be a very appropriate form of treatment for people with schizophrenia as several symptoms of schizophrenia are mainly cognitive in nature, such as the negative delusions, hallucinations and the disorganised speech, therefore CBT as a psychotherapy could be used to counteract these symptoms very successfully. CBT could also be useful in putting the patient’s minds at ease, for example patients with schizophrenia are often concerned about their bizarre delusions and hallucinations, but realising during therapy that similar delusions and hallucinations sometimes occur in healthy people may be useful in improving their mental state.
On the other hand, there are some downfalls of CBT within the treatment of schizophrenia, for example, CBT is designed to reduce only certain positive symptoms so it is not appropriate form of treatment for reducing or eliminating negative symptoms, such as the lack of emotion. Therefore could be quite a reductionist approach. Also CBT, does not take into account biological factors or the biochemistry behind the possible cause of schizophrenia, therefore also another reductionist argument against CBT.