Schizophrenia

Schizophrenia can affect anyone, and is one of the greatest causes of lost quality of life worldwide. One-in-100 people will experience this serious mental illness at some time in their lives, though it commonly starts in the late teens to the early 20s in men and early to late 20s in women. Although schizophrenia can have a profound effect, it can be treated effectively in most people. This was not always the case.

Chlorpromazine initiated a revolution in the treatment of people with schizophrenia and was the first truly effective therapy. Thus, many patients were able to leave mental institutions and live in their own communities. Chlorpromazine, in common with all antipsychotics, acts by blocking or reducing the function of dopamine receptors. The antipsychotics in general use up until the 1990s are often called typical or conventional antipsychotics. These are less effective against negative than positive symptoms, and elicit extrapyramidal side-effects (EPS), often at doses which do not improve schizophrenia symptoms. The reintroduction of clozapine led to the subsequent advent of the ‘atypical’ antipsychotics. Although not really a separate class of antipsychotics, these medications are characterised by vastly reduced or absent EPS at therapeutic doses. Their use has been associated with dramatic improvements in the secondary negative symptoms of schizophrenia which were often related to EPS. However, clozapine is restricted to use in treatment-resistant schizophrenia as regular blood monitoring is required. Other atypical antipsychotics (e.g. risperidone, olanzapine, quetiapine, amisulpride and ziprasidone) have subsequently been developed. Though none seem to be quite as effective as clozapine in treatment-resistant schizophrenia, they do not require blood monitoring, have a greater effect against negative symptoms globally and cause fewer EPS than the typical antipsychotics.

Recently published UK guidelines from the National Institute of Clinical Excellence, (NICE), advocate that atypical antipsychotics should be made available to all patients with schizophrenia, yet a survey carried out by the charity Rethink suggests that about 20% of primary care trusts (PCTs) have yet to make these drugs available for doctors to prescribe for people with schizophrenia, presumably as their acquisition costs are greater than the older typical antipsychotics. Hopefully, the more widespread use of newer antipsychotics will reduce the side-effect burden on people treated for schizophrenia, fulfilling patients’ basic human rights to lead the most normal and productive lives they can.

The development of better resources should go hand-in-hand with better treatment. For example, a relatively small number of acute inpatient beds needs to be combined with half-way and respite houses, outpatient clinics, occupational therapy, and in general, an emphasis on the rehabilitation of patients into the ordinary activities of daily living. Thus, the greater integration of primary care – in the form of GPs and community psychiatric nurses and social workers who work directly with them – with specialist care (primarily psychiatrists and hospital and community mental health teams), is both desirable and necessary. One possible challenge to both primary and secondary care is that as we become better at treating schizophrenia a greater burden could fall on primary care, as more patients are treated for longer in the community outside of specialist services. We need to foster stronger links between psychiatrists and primary care, ensure that patients’ symptoms are recognised as early as possible and that appropriate action (e.g. referral to a specialist) is taken.

It is in primary care that recognition of patient risk factors and detection of illness usually occurs. Thus, effective primary–secondary care communication and integration is essential, will lead to the best use of existing resources and allow for the compassionate care of people with schizophrenia in as close to an ordinary home environment as possible. The eventual benefits of this approach may be an improvement in the long-term outcome for people with schizophrenia.

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This Editorial has been written by the specialist opinion leader Dr Mike Travis

Consultant and Honorary Senior Lecturer, Maudsley Hospital and Institute of Psychiatry, King’s College London, and published in the latest issue of the serial publication, Drugs in Context.

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