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Schizophrenia: care for the 21st century

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VOL: 98, ISSUE: 40, PAGE NO: 36

Tony Gillam, BA, RMN, Dip.CPN, is community psychiatric nurse, Worcestershire Mental Health Partnership NHS Trust

Schizophrenia is one of several mental illnesses that fall under the heading of psychosis. The exact cause or causes of schizophrenia remain unclear but genetic, environmental and social factors are all thought to influence its development. Genetic factors seem to predispose certain people to the disorder, while environmental and social factors, such as stressful life events, can precipitate its onset or a relapse.

Schizophrenia is one of several mental illnesses that fall under the heading of psychosis. The exact cause or causes of schizophrenia remain unclear but genetic, environmental and social factors are all thought to influence its development. Genetic factors seem to predispose certain people to the disorder, while environmental and social factors, such as stressful life events, can precipitate its onset or a relapse.

One out of every 100 people in the UK between the ages of 16 and 64 years old will develop schizophrenia at some point in their life. A GP with 1,800 patients could expect to see one new presentation of schizophrenia every five years (Cohen and Singh, 2001).

The illness affects men and women in equal numbers, but usually develops in men in their late teens or early 20s, and in women a little later. In the UK about 250,000 people have a diagnosis of schizophrenia. About one-third of homeless people in the UK have the disorder.

One in 10 people with schizophrenia commit suicide. However, most people have long periods in which they function well, so it is vital to instil hope and maintain realistic levels of optimism in patients, families and carers.

Psychosocial interventions
While medication remains central to the treatment of schizophrenia, pharmacological treatment alone is insufficient to help with the psychological and social impact of the illness on patients, their families and carers. A number of 'psychosocial interventions' are used, including:

- Individual, family and group work with patients/carers;

- Behavioural family therapy;

- Psycho-educational groups with carers;

- Cognitive behavioural therapy (CBT).

More broadly, psychosocial interventions acknowledge the principles of care coordination, assertive outreach and, where possible, early intervention (Box 1).

The popular growth of psychosocial interventions
In 1995, the government published Building Bridges: A guide to arrangements for inter-agency working for the care and protection of severely mentally ill people (Department of Health, 1995). It stated that community mental health nurses should refocus their activities on meeting the needs of people with severe and enduring mental illness. The guide said that nurses needed clinically effective skills to work with this client group. This in turn prompted the introduction of new training courses.

The Thorn nursing programme had been running since 1992. Initially a postregistration course in London and Manchester, it produced nurses skilled in the care of people with severe mental illness in the community. In recent years, similar courses have developed in other parts of the UK. Typically, theoretical and clinical work are combined and a cognitive behavioural family therapy approach is used.

Cognitive behavioural therapy for psychotic symptoms

Studies in the 1980s and 1990s explored the use of psychological techniques to manage psychotic symptoms. Nelson et al (1991) compared three techniques for treating auditory hallucinations, using ear plugs, a personal cassette recorder, and various vocalisation techniques. All three were found to provide some benefit, with the personal cassette player being the most effective.

Nelson et al see such psychological interventions as useful additions to pharmacological treatment, but some believe that CBT 'may provide both complementary and alternative strategies to traditional medical treatment' (Bradshaw, 1995).

As well as treating hallucinations, CBT has also been used to treat delusional beliefs. Bradshaw (1995) says 'the technique works by challenging the evidence supporting the delusional belief rather than directly confronting the belief itself'. CBT can provide short-term and longer-term strategies for treating delusions and hallucinations, and help to build therapeutic alliances with patients concerning the taking of medication.

Monitoring early warning signs

Many people with schizophrenia experience early warning (prodromal) signs in the four weeks prior to relapse (Subotnik and Nuechterlein, 1988). It has been hypothesised that, if the patient was able to predict relapse, intervention could avert it early in the prodromal phase.

Birchwood et al (1989) suggest that patients may have an individual 'relapse signature', which they and their carers could learn to recognise and act on. Monitoring early warning signs can be done with patients or as part of a behavioural family therapy intervention where the family help identify subtle changes the patient may be unaware of.

Family intervention

This was one of three key areas covered by the Thorn nursing programme (along with case management and psychological management of psychotic symptoms). There is a large evidence base to support the use of psycho-educational family intervention. Mari et al (1997) proved that it: reduced the rate of relapse at 12, 18 and 24 months; reduced hospital admission rates at one year and beyond; and helped to improve concordance with the taking of medication.

Due to demonstrable reductions in relapse and readmission and greater cooperation with treatment approaches, there has been a drive to train nurses and other mental health workers in providing family intervention.

The Meriden Family Programme in the West Midlands has now trained more than 1,000 people in behavioural family therapy. The intervention usually involves: assessment of individual family members and the family as a whole; education about the illness and its treatment, including early warning signs; and the teaching of communication skills and problem-solving (Gillam, 2002).

Pharmacological interventions
Nelson (1997) says: 'For nearly all people with schizophrenia, antipsychotic medication offers the best chance of gaining relief from their symptoms ... the range of antipsychotic drugs now available is such that very few patients get no benefit at all from medication and so taking the medication prescribed is ... their most important coping strategy'. The drugs referred to include older, typical antipsychotics and the newer so-called 'atypicals'.

Typicals and atypicals

The first antipsychotic agent, a phenothiazine called chlorpromazine, became available in 1954. This was followed by other phenothiazines and more potent agents such as haloperidol. Although cheap and effective at managing the positive symptoms of schizophrenia, they produced extrapyramidal side-effects, such as:

- Parkinsonian symptoms (including tremor);

- Dystonia (abnormal face and body movements);

- Akathisia (motor restlessness);

- Tardive dyskinesia (involuntary chewing motions, which may develop after long-term use of these drugs).

A raised prolactin level (hyperprolactinaemia) is another distressing but often unrecognised or under-reported side-effect. In women, it results in abnormal menstruation and infertility. In men, it causes sexual dysfunction. It can cause the abnormal production of breast milk in both men and women.

Atypical antipsychotics became available in the 1990s. These appear at least as effective as the older antipsychotics (now dubbed 'typical' antipsychotics) but seem to be better tolerated due to their improved side-effect profile.

Atypical antipsychotics under review

The National Institute for Clinical Excellence (NICE) recommended the use of atypical antipsychotics for schizophrenia in June 2002, following a series of reports by the National Schizophrenia Fellowship (NSF), now known as Rethink, in collaboration with the Manic Depression Fellowship and mental health charity Mind (NSF, 2000; 2001; 2002). The reports argue that while atypicals are more expensive than the older antipsychotics, the improved compliance rates, which lead to reduction in relapse and rehospitalisation, make them more cost-effective.

The reports also suggest that the personal impact of side-effects should be assessed individually and medicine should be selected, monitored and possibly changed accordingly. After NICE's endorsement of atypicals, the debate is now on which atypical to choose (Box 2).

Conclusion
There is little evidence that psychosocial interventions are helpful in schizophrenia if the patient is not receiving effective medication. Psychosocial and pharmacological approaches are mutually supportive and complementary. Organisations representing patients, their families and carers are keen to be given the choice of atypical antipsychotics, as well as access to psychosocial approaches.

The government supports the use of psychosocial interventions and atypical antipsychotics. The National Service Framework for Mental Health (DoH, 1999) promotes effective treatment and care that optimises engagement, anticipates or prevents a crisis, and reduces risk. It also stresses the need to promote the social inclusion of the mentally ill, and the importance of assessing carers' needs.

With government policy, an impressive evidence base and an increasingly skilled mental health workforce, perhaps we can be more hopeful about the future.

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