• 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