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Management of schizophrenia usually involved many aspects including psychological, pharmacological, social, educational, and employment-related interventions directed to recovery, reducing the impact of the disease on quality of life, social functioning, and longevity.
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Hospitalization
Hospitalization may occur with severe episodes of schizophrenia. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or involuntary commitment). Long-term inpatient stays are now less common due to deinstitutionalization, although still occur. Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or Assertive Community Treatment team, supported employment and patient-led support groups. Efforts to avoid repeated hospitalization include the obtaining of community treatment orders which,following judicial approval, coerce the affected individual to receive psychiatric treatment including long-acting injections of anti-psychotic medication. This legal mechanism has been shown to increase the affected patient's time out of the hospital.
Medication
The mainstay of psychiatric treatment for schizophrenia is antipsychotic medication. Medication might improve a number of outcomes found to be important to patients, including positive, acute and psychotic symptoms, and social and vocational functioning. Medication can reduce the "positive" symptoms of psychosis. Most antipsychotics are thought to take around 7 to 14 days to have their main effect. However, these drugs fail to significantly ameliorate the negative symptoms and cognitive dysfunction. There is evidence of clozapine, amisulpride, olanzapine and risperidone being the most effective medications, although a high proportion of studies of risperidone were undertaken by its manufacturer, Janssen-Cilag, and should be interpreted with this in mind. In those on antipsychotics, continued use decreases the risk of relapse. There is little evidence regarding consistent benefits from their use beyond two or three years.
Treatment of schizophrenia changed dramatically in the mid-1950s with the development and introduction of the first antipsychotic chlorpromazine. Others such as haloperidol and trifluoperazine soon followed.
It remains unclear whether the newer antipsychotics reduce the chances of developing neuroleptic malignant syndrome, a rare but serious and potentially fatal neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs.
Most people on antipsychotics get side effects. People on typical antipsychotics tend to have a higher rate of extrapyramidal side effects while some atypicals are associated with considerable weight gain, diabetes and risk of metabolic syndrome; this is most pronounced with olanzapine, while risperidone and quetiapine are also associated with weight gain. Risperidone has a similar rate of extrapyramidal symptoms to haloperidol. The American Psychiatric Association generally recommends that atypicals be used as first line treatment in most patients, but further states that therapy should be individually optimized for each patient.
Response of symptoms to medication is variable; "Treatment-resistant schizophrenia" is the failure to respond to two or more antipsychotic medications given in therapeutic doses for six weeks or more. Patients in this category may be prescribed clozapine, a medication of superior effectiveness but several potentially lethal side effects including agranulocytosis and myocarditis. Clozapine is the only medication proven to be more effective for persons who do not respond to other types of antipsychotics. It also appears to reduce suicide in people with schizophrenia. As clozapine suppresses the development of bone marrow, in turn reducing white blood cells which can lead to infection, blood tests are taken for the first six months on this medication. A update to the existing Cochrane review was done in 2009; which showed that clozapine though effective, has its own adverse(dangerous) effects in the form of decline in white blood cell count seen frequently in children,and adolescents. The effectiveness in the studies also needs to be interpreted with caution as the studies may have an increased risk of bias.
Adjunctive agents in schizophrenia
Note: Only adjuncts for which at least one double-blind randomized placebo-controlled trial has provided support are listed in this table.
Acronyms used:
DB-RPCT — Double-blind randomized placebo-controlled trial.
DB-RCT — Double-blind randomized controlled trial.
AE — Adverse effect.
Note: Global in the context of schizophrenia symptoms here refers to all four symptom clusters.
† No secondary sources could be found on the utility of the drug in question, treating the symptom in question (or any symptom in the case of where † has been placed next to the drug's name).
Psychosocial
Psychotherapy is also widely recommended, though not widely used in the treatment of schizophrenia, due to reimbursement problems or lack of training. As a result, treatment is often confined to psychiatric medication.
Cognitive behavioral therapy (CBT) is used to target specific symptoms and improve related issues such as self-esteem and social functioning. Although the results of early trials were inconclusive as the therapy advanced from its initial applications in the mid-1990s, meta-analytic reviews suggested CBT to be an effective treatment for the psychotic symptoms of schizophrenia. Nonetheless more recent meta analyses have cast doubt upon the utility of CBT as a treatment for the symptoms of psychosis
Another approach is cognitive remediation therapy, a technique aimed at remediating the neurocognitive deficits sometimes present in schizophrenia. Based on techniques of neuropsychological rehabilitation, early evidence has shown it to be cognitively effective, resulting in the improvement of previous deficits in psychomotor speed, verbal memory, nonverbal memory, and executive function, such improvements being related to measurable changes in brain activation as measured by fMRI.
Metacognitive training: In view of a many empirical findings suggesting deficits of metacognition (thinking about one’s thinking, reflecting upon one’s cognitive process) in patients with schizophrenia, metacognitive training (MCT) is increasingly adopted as a complementary treatment approach. MCT aims at sharpening the awareness of patients for a variety of cognitive biases (e.g. jumping to conclusions, attributional biases, over-confidence in errors), which are implicated in the formation and maintenance of schizophrenia positive symptoms (especially delusions), and to ultimately replace these biases with functional cognitive strategies.
The training consists of 8 modules and can be obtained cost-free from the internet in 15 languages. Studies confirm the feasibility and lend preliminary support to the efficacy of the intervention. Recently, an individualized format has been developed which combines the metacognitive approach with methods derived from cognitive-behavioral therapy.
Family Therapy or Education, which addresses the whole family system of an individual with a diagnosis of schizophrenia, has been consistently found to be beneficial, at least if the duration of intervention is longer-term. Aside from therapy, the impact of schizophrenia on families and the burden on careers has been recognized, with the increasing availability of self-help books on the subject. There is also some evidence for benefits from social skills training, although there have also been significant negative findings. Some studies have explored the possible benefits of music therapy and other creative therapies.
The Soteria model is alternative to inpatient hospitalization using full non professional care and a minimal medication approach. Although evidence is limited, a review found the programme equally as effective as treatment with medications but due to the limited evidence did not recommend it as a standard treatment. Training in the detection of suble facial expressions has been used to improve facial emotional recognition.
Diet
An unconventional approach is the use of omega-3 fatty acids, with one study finding some benefits from their use as a dietary supplement.
A 2003 review of four randomized controlled trials of EPA (an omega-3 fatty acid) vs. placebo as adjunctive treatment for schizophrenia found that two of the trials detected a significant improvement on positive and negative symptoms, and suggested that EPA may be an effective adjunct to antipsychotics. The most recent meta-analysis (2006) failed however to find a significant effect. A 2007 review found that studies of omega-3 fatty acids in schizophrenia, despite being mostly of high quality, have produced inconsistent results and small effect sizes of doubtful clinical significance. Individualized nutrition interventions and supplementation has been proposed as an adjunct to pharmacological therapy in people with schizophrenia, though this approach has not been evaluated in clinical trials to determine the efficacy of such an approach in improving symptoms.
Other
Transcranial Magnetic Stimulation (TMS) appears to be effecting in alleviating the negative symptoms and cognitive deficits see in schizophrenia, a recent double-blind randomized sham controlled study of deep-TMS add-on treatment noted an 8-point reduction in the Scale for the Assessment of Negative Symptoms (SANS) in patients.
Electroconvulsive therapy is not considered a first line treatment but may be prescribed in cases where other treatments have failed. It is more effective where symptoms of catatonia are present, and is recommended for use under NICE guidelines in the UK for catatonia if previously effective, though there is no recommendation for use for schizophrenia otherwise. Psychosurgery has now become a rare procedure and is not a recommended treatment for schizophrenia.