Treatment Strategies (Part 2): Novel Treatments
Foreword on Novel Treatment Strategies
Current State of Treatment: There are significantly more treatment options available for schizophrenia spectrum disorders than simply dopamine blockers.
Future Potential: Some of these novel treatments may eventually replace current medications entirely.
Targeted Symptoms: New treatments are specifically being developed to target the symptoms that cause the most disability in patients: * Negative Symptoms. * Cognitive Dysfunction.
Timeline for Change: Due to the increased focus of the National Institutes of Health (NIH) on this cluster of disorders, a major restructuring of treatment protocols is very likely within the next years.
Bioelectronic Medicine (Neuromodulation)
Definition: Non-invasive treatment techniques that modulate the activity of the nervous system. This is typically achieved through the precise delivery of an electrical current or manipulation using magnets.
Clinical Utility: Neuromodulation is particularly promising for treating Negative and Cognitive symptoms.
Specific Types of Neuromodulation: * Transcranial Magnetic Stimulation (TMS). * Transcranial Direct Current Stimulation (tDCS). * Intermittent Theta Burst Stimulation (iTBS). * Electroconvulsive Therapy (ECT).
Safety Profile: One of the most relevant aspects of these treatments is that they might be used safely in children.
Transcranial Direct Current Stimulation (tDCS)
Mechanism of Action: This form of neuromodulation uses a constant, low, direct electrical current delivered via electrodes placed on the head.
Polarity Effects: * Anodal tDCS (Positive Stimulation): Delivered to increase neuronal excitability and allow for more spontaneous cell firing. * Cathodal tDCS (Negative Stimulation): Delivered to decrease neuron excitability.
Personalization: Treatment can be personalized using an individual’s own brain map.
Clinical Benefits: * Negative Symptoms and Catatonia: Application over both prefrontal cortices has been shown to reduce these symptoms. * Cognitive Function: Improvement has been reported across a range of regions for learning, working memory, attention, and source-monitoring. * Social Cognition: Currently the subject of ongoing studies. * Other Symptoms: Evidence suggests effectiveness for auditory hallucinations and improving overall symptoms in treatment-resistant patients.
Intermittent Theta Burst Stimulation (iTBS)
Mechanism: Uses magnets to provide "clusters" of stimulation intended to excite a specific area of the cortex.
Physiological Impact: Increases brain metabolism and electrical activity in the region of application.
Functional Impact: Typically results in increased functional connectivity of the region it is applied to.
Administration: * Duration: Much shorter than tDCS, lasting less than compared to the required for tDCS. * Precision: Can be applied using information from an individual’s brain MRI.
Schizophrenia Research (Tan et al 2024): The use of iTBS in schizophrenia is fairly new. When performed correctly, it is very promising for individuals with severe negative symptoms. A recent meta-analysis suggests: * Negative Symptoms: Small effect. * Positive Symptoms: No impact. * Cognitive Symptoms: No impact.
Electroconvulsive Therapy (ECT)
Procedure: Involves a brief but powerful electrical current passed into the brain to induce a seizure.
Setting: Performed while the patient is under anesthesia, typically in a surgical suite with a full medical team.
Mechanism of Action: Very unclear, as it essentially activates every single cell in the brain.
Patient Selection: Typically reserved for treatment-resistant individuals because it is expensive, time-consuming, and carries many adverse effects.
Efficacy: Exceptionally effective, with over of patients demonstrating significant improvement in core symptoms.
Cognitive Remediation
Objective: Intended to address cognitive difficulties accompanying schizophrenia to enhance function and quality of life.
Format: Typically delivered in group or computer-based formats.
Targeted Processes: * Attention. * Memory. * Executive function. * Social cognition. * Meta-cognition.
Supplemental Elements: Some programs add social and communication skills to neurocognitive elements. Web-based programs are available for patients who lack access to in-person services.
Benefits: * Significant improvement in negative symptoms. * Small positive effect on social, occupational, living situation, and global function. * Small improvements in core illness symptoms.
Drawbacks: Virtually none, other than the burden of time and effort on the patient.
Social Skills Training (SST)
Goal: To improve interpersonal and social skills.
Delivery Methods: Individual administration, group formats, and increasingly, Virtual Reality (VR).
Augmentation Strategy: Group sessions can be enhanced with: * Video or technologically based interventions. * In vivo community trips to practice skills. * Involvement of support persons who are accessible and knowledgeable about local resources/limitations.
Benefits: * Significantly better social function. * Improvement in Negative Symptoms. * Greater improvement in core illness symptoms.
Cognitive-Behavioral Therapy for Psychosis (CBTp)
Distinction: Differs from standard CBT for other indications.
Focus: Guides patients to develop their own healthier and realistic alternative explanations for maladaptive cognitive assumptions. It aims to stop the perpetuation of convictions regarding the veracity of hallucinatory experiences or delusional beliefs.
Resources: Instructional videos available at: www.icanfeelbetter.org/cbtpskills
Implementation: * Can be started in any treatment setting (including inpatient) and during any phase of the illness. * Formats: Group, individual, in-person, or Web-based. * Target Audience: Patients and their family members or support persons. * Duration: Varies between and , though is generally recommended.
Outcomes: * Short-term: Better global and social/occupational function; better quality of life. * Short and Long-term: Fewer core illness symptoms. * No Effect: Does not affect negative symptoms; does not impact global/social/occupational function or quality of life in the long term.
Assertive Community Treatment (ACT)
Model: A multidisciplinary, team-based approach where patients receive individualized care outside clinical settings (homes, workplaces, community locations).
Nature of Care: Personalized, flexible, and addresses patient preferences without time limits or service constraints.
Team Structure: ACT teams work with a smaller number of individuals compared to traditional case managers or outpatient clinicians.
Benefits: * Reduction in homelessness. * Reduction in unemployment. * Lower likelihood of hospital admission. * Shorter duration of stays if hospitalized.
Ineffective Areas: Does not affect core illness symptoms or social function over and above Treatment as Usual (TAU).
Family Interventions
Nature: Systematically delivered interventions focusing on the future rather than past events, extending beyond simple information conveyance.
Approaches: * Structured problem-solving. * Training in coping with symptoms. * Improving family communication. * Providing emotional support. * Strategies for reducing stress and enhancing social support networks.
Participation: May or may not include the patient; can be single-family or multifamily groups.
Benefits: * Reduction in core illness symptoms. * Lower relapse rates for up to following the intervention.
Ineffective Areas: Does not impact social functioning, independent living, or unemployment.
Basic Interventions and Wellness
General Life Improvements: Individuals with Schizophrenia Spectrum Disorders benefit from basic interventions that improve general well-being: * Regular exercise. * A balanced, proper diet. * Receiving and giving social support. * Maintaining optimism. * Building resilience.
Well-Being Impact: Engaging in these activities makes a difference regardless of the patient's starting point.
Exam 3 Information
Status: Not "Optional."
Format: Same as the previous two exams.