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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

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