Chapter Fifteen: Treatments for Schizophrenia and Other Severe Mental Disorders

  • Antipsychotic drugs help many people with psychotic disorders to think clearly

Institutional Care in the Past

  • Most people diagnosed with schizophrenia were institutionalized in a public mental hospital
  • Primary goals of these hospitals were to restrain them and give them food, shelter, and clothing
  • Patients were neglected and many were abused
  • Moral treatment led to the creation of large mental hospitals rather than asylums to care for those with severe mental disorders
  • State Hospitals: Public mental hospitals in the US run by individual states for patients who couldn’t afford private ones
  • State hospitals become overcrowded and priorities changed from giving humanitarian care to keeping order
      * Difficult patients were restrained, isolated, and punished
      * Individual attention disappeared
      * Patients were transferred to chronic wards if they failed to improve quickly
      * Staff members relied on straitjackets and handcuffs to deal with difficult patients
  • Many patients failed to improve under these conditions and also developed additional symptoms
  • Social Breakdown Syndrome: Extreme withdrawal, anger, physical aggressiveness, and loss of interest in personal appearance and functioning
      * Made it impossible for patients to return to society even if they somehow recovered from the symptoms that had first brought them to the hospital

Institutional Care Takes a Turn for the Better

Milieu Therapy
  • A humanistic approach to institutional treatment based on the premise that institutions can help patients recover by creating a climate that promotes self-respect, responsible behavior, and meaningful activity
  • Maxwell Jones
  • Patients were referred to as residents and were regarded as capable of running their own lives and making their own decisions
  • Atmosphere was one of mutual respect, support, and openness
  • Daily schedule was designed to resemble life outside the hospital
The Token Economy
  • A behavior-focused program in which a person’s desirable behaviors are reinforced systematically by the awarding of tokens that can be exchanged for goods or privileges
  • Patients are rewarded when they behave acceptably and not rewarded when they behave unacceptably
  • Help reduce psychotic and related behaviors
  • Uncontrolled - improvements can be compared only with their past behaviors
  • Patients have certain basic rights that clinicians can’t violate, regardless of the positive goals of a treatment program
  • It’s been difficult for patients to make a satisfactory transition from hospital token economy programs to community living

Antipsychotic Drugs

  • Drugs that help correct grossly confused or distorted thinking
  • First-generation / Neuroleptic Drugs: Drugs that often produce undesired effects similar to the symptoms of neurological disorders
  • Antipsychotic drugs reduce psychotic symptoms by blocking excessive activity of dopamine
How Effective Are Antipsychotic Drugs?
  • Reduce symptoms in around 70% of patients diagnosed with schizophrenia
  • Appear to be a more effective treatment than any of the other approaches used alone
  • Medications bring about clear improvement within a period of weeks
  • Symptoms may return if the patients stop taking the drugs too soon
  • Reduce the positive symptoms of schizophrenia more completely and quickly than the negative symptoms
  • Patients often dislike the powerful effects of the drugs and refuse to take them
The Unwanted Effects of First-Generation Antipsychotic Drugs
  • Extrapyramidal effects: Unwanted movements, such as severe shaking, bizarre-looking grimaces, twisting of the body, and extreme restlessness, sometimes produced by antipsychotic drugs
  • Parkinsonian and Related Symptoms
      * Reactions that closely resemble the features of Parkinson’s disease
      * Muscle tremors and muscle rigidity
      * Shake, move slowly, shuffle their feet, and show little facial expression
      * Movements of the face, neck, tongue, and back
      * Significant restlessness and discomfort in the limbs
      * Result of medication-induced reductions of dopamine activity in the striatum
      * Symptoms can be reversed if the person takes an anti-Parkinsonian drug along with the antipsychotic drug
  • Neuroleptic Malignant Syndrome: A severe, potentially fatal reaction consisting of muscle rigidity, fever, altered consciousness, and improper functioning of the autonomic nervous system
  • Tardive Dyskinesia: Extrapyramidal effects involving involuntary movements that some patients have after they have taken antipsychotic drugs for an extended time
      * Most cases are mild and involve a single symptom
      * More than 15% of the people who take first-generation antipsychotic drugs for an extended time develop tardive dyskinesia to some degree
        * The longer the drugs, the higher the risk becomes
        * Patients over 50 yrs are at a greater risk
      * Can be difficult to eliminate
        * If discovered early and drugs are stopped immediately, disappears in 90% of cases
        * Early detection is elusive - some of the symptoms are similar to psychotic drugs
        * In late detection, symptoms disappear in 40% of cases
  • Clinicians try to prescribe the lowest effective doses for each patient
  • Gradually reduce medications weeks or months after the patient begins functioning normally
Second-Generation Antipsychotic Drugs
  • Received at fewer dopamine D-2 receptors and more D-1, D-4, and serotonin receptors
  • At least as effective and often more effective than first-generation drugs
  • Clozapine is the most effective
  • Reduce positive and negative symptoms of schizophrenia
  • Cause fewer extrapyramidal symptoms
  • Seem less likely to produce tardive dyskinesia
      * Second-generation drugs are less likely to be received by D-2 receptors, which are the receptors most involved in the development of tardive dyskinesia
      * Clozapine is the least likely to cause tardive dyskinesia
  • Considered the first line of treatment
  • Agranulocytosis: A life-threatening drop in white blood cells sometimes produced by clozapine
  • May cause weight gain, dizziness, metabolic problems, sexual dysfunctions, and cardiovascular changes
  • Medications typically produce only modest changes in overall life satisfaction among those who have chronic schizophrenia

Psychotherapy

  • First task: win the trust of patients and build a close relationship with them
Cognitive-Behavioral Therapies
  • Cognitive Remediation: An approach that focuses on the cognitive impairments that often characterize people with schizophrenia
      * Difficulties in attention, planning, and memory
      * Complete increasingly difficult information-processing tasks on a computer
      * Brings about moderate improvements in attention, planning, and problem-solving
      * Improvements extend to the client’s everyday life and social relationships
  • Hallucination reinterpretation and acceptance
      * Become detached and comfortable observers of their hallucinations
      * Move forwards with the tasks and events of their lives
      * Feel less distress by their hallucinations and have fewer delusions
Family Therapy
  • A patient’s recovery may be strongly influenced by the behavior and reactions of their relatives at home
  • People with schizophrenia who feel positive toward their relatives do better in treatment
  • Recovered patients living with relatives who display high levels of expressed emotion often have a much higher relapse rate than those living with more positive and supportive relatives
  • Family members may be very upset by the social withdrawal and unusual behaviors of a relative with schizophrenia
  • Clinicians now commonly include family therapy in their treatment of schizophrenia
  • Helps reduce tensions within the family
  • Helps relapse rates and hospital readmissions go down
Social Therapy
  • Techniques that address social and personal difficulties in the client’s lives
  • Help keep people out of the hospital
  • Those on medication who also received social therapy adjusted to the community and avoided rehospitalization most successfully

The Community Approach

  • Community Mental Health Act: Patients with psychological disorders were to receive a range of mental health services in their communities rather than being transported to institutions far from home
  • Deinstitutionalization: The discharge of large numbers of patients from long-term institutional care
  • Patients recovering from schizophrenia and other severe disorders can profit greatly from community programs
  • Actual quality of community care for these people has often been inadequate in the US
What Are the Features of Effective Community Care?
  • Coordinated Services
      * Community Mental Health Centers: A treatment facility that provides medication, psychotherapy, and emergency care for psychological problems and coordinates treatment in the community
      * Patients with schizophrenia and other severe disorders often make significant process
      * Particularly important for so-called mentally ill chemical abusers
      * Mentally Ill Chemical Abusers: Patients with psychotic disorders as well as substance use disorders
  • Short-Term Hospitalization
      * Lasts a few weeks, rather than months or years
      * After patients, improve, they’re released for aftercare
      * Aftercare: A program of posthospitalization care and treatment in the community
      * Usually leads to more improvement and a lower rehospitalization rate than extended institutionalization
  • Partial Hospitalization
      * Day Center: A program that offers hospital-like treatment during the day only
        * Provide patients with daily supervised activities, therapy, and programs to improve social skills
        * Often do better and have fewer relapses than those who spend extended periods in a hospital or in traditional outpatient therapy
      * Semihospital / Residential Crisis Center: Houses in the community that provide 24-hr nursing care for people with severe mental disorders
  • Supervised Residences
      * Halfway houses
      * Live-in staff are usually paraprofessionals
      * Paraprofessionals: People who receive training and ongoing supervision from outside mental health professionals
      * Houses usually run with a milieu therapy philosophy
      * Help many people recovering from schizophrenia and other severe disorders adjust to community life and avoid rehospitalization
  • Occupational Training and Support
      * Sheltered Workshop: A supervised workplace for employees who are not ready for competitive or complicated jobs
      * Replicates a typical work environment
      * Can become a permanent workplace
      * Supported Employment: Vocational agencies and counselors help clients find competitive jobs in the community and provide psychological support while the clients are employed
        * Often in short supply
      * Fewer than 20% of individuals with severe psychological disorders have jobs in the competitive job market
How Has Community Treatment Failed?
  • Fewer than half of all the people who need them receive appropriate community mental health services
  • 40-60% of all people with schizophrenia and other severe mental disorders receive no treatment
  • Poor Coordination of Services
      * Mental health agencies often fail to communicate with each other
      * Patient may not have continuing contacts with the same staff members
      * Patient may fail to receive consistent services
      * Poor communication between state hospitals and community mental health centers, particularly at times of discharge
      * Case Manager: A community therapist who offers and coordinates a full range of services for people with schizophrenia or other severe disorders
  • Shortage of Services
      * Fail to provide adequate services for people with severe disorders
      * Economic reasons
        * More public funds are available for people with psychological disorders now than in the past
        * Little of the additional money is going to community treatment programs
        * Financial burden of providing community treatment falls on local governments and nonprofit organizations
  • Consequences of Inadequate Community Treatment
      * Return to their families
        * Receive little treatment
        * Medication
        * Emotional and financial support
      * Nursing home
        * Custodial care
        * Medication
      * Privately run residences
        * Supervision is often provided by untrained staff
        * Vary in quality
        * Minimal services
      * Live in totally unsupervised settings
        * Some can support themselves
        * Others can’t function independently
      * Become homeless
        * ¼ of homeless people in the US have a severe mental disorder
      * Many are in prisons and jails because their disorders have led them to break the law
The Promise of Community Treatment
  • Proper community care has great potential
  • Pushing to make it more available
      * Clinicians
      * Government officials
      * National interest groups have formed