A Guide for the Care and Treatment of Patients with Schizophrenia

What Is Schizophrenia?

Schizophrenia is a biologic brain disorder that seriously impairs a person's ability to think clearly and relate to others. People with schizophrenia have trouble distinguishing between what is real and what is imaginary and may become withdrawn or have difficulty in everyday situations.

Schizophrenia typically develops in adolescence or early adulthood, although it may occur later in life. Schizophrenia usually progresses slowly and varies among patients in its severity.

What Are the Symptoms of Schizophrenia?

Symptoms of schizophrenia generally are categorized as 1 of 3 types:

Positive symptoms: abnormal or exaggerated behaviors or patterns of thought that are "added" to an individual's way of interacting with the world. These include visual, auditory, and/or tactile hallucinations (seeing, hearing, and feeling things that don't exist), persistent delusions (false beliefs that aren't changed by reason or evidence), paranoid delusions, and disorganized or unusual thought processes and speech. Side effects or symptoms of medications also include movement disorders, including clumsiness, uncoordinated or involuntary movements, and rarely, catatonia.

Negative symptoms: the absence, loss, or reduction of normal behaviors, emotions, and patterns of thought. Examples include blunted emotions, inability to begin and follow through with activities, social withdrawal, negligent hygiene, and displeasure or disinterest in life.

Cognitive symptoms: difficulties with attention, memory, and executive functioning that interfere with normal daily activities.

As the illness progresses, these symptoms often become more intense. Schizophrenia often works in cycles, meaning the disease may get better and then reoccur at a later date.

What is the History of Schizophrenia?

While the word "schizophrenia" is less than 100 years old, the illness itself is generally believed to have been present in humans since the beginning of mankind. It was not until 1887, however, that it was first recognized as a discrete mental disorder by German physician Emile Kraepelin. He used the term "dementia praecox" (meaning "early dementia") for patients who had symptoms that are now associated with schizophrenia. In 1911, Eugen Bleuler, a Swiss psychiatrist, coined the term "schizophrenia," (derived from the Greek words "schizo," meaning "split," and phrene, meaning "mind").

He was also the first to characterize the symptoms as either "positive" or "negative." Bleuler thought dementia praecox was misleading because the illness was not a form of dementia and could occur late as well as early in life. He therefore believed that schizophrenia was a more appropriate name and conveyed the fragmented thought processes of people who suffer from the disease.

How Many People Have Schizophrenia?

Worldwide, it is estimated that 1 person in every 100 develops schizophrenia. There are currently more than 2 million Americans who have schizophrenia, with men and women affected equally. Because of the typically early age of onset and the lifelong burden of the disease on patients' emotional and physical well-being, schizophrenia can be considered one of the most debilitating medical conditions.
According to the American Psychiatric Association, patients with schizophrenia occupy more hospital beds than do patients with almost any other illness. Federal costs of the disease total between $30 billion and $48 billion per year, when direct medical costs, lost productivity, and Social Security payments are considered.vi It is estimated that 50% to 80% of patients with schizophrenia live with or have routine contact with family members who are their caregivers. There is a corresponding huge burden placed on caregivers. Schizophrenia imposes significant personal, financial, social, and emotional demands on caregivers. Other estimates therefore place the overall cost of schizophrenia at nearly $63 billion, when direct healthcare, societal, and family and caregiver costs are totaled.

How Is Schizophrenia Treated?

Although the cause of schizophrenia remains unknown, antipsychotic medications can help people with this illness function better and more appropriately. In conjunction with counseling programs designed to help people manage and cope with their behavioral symptoms, these medications have been proven to significantly alleviate psychotic symptoms and reduce the chances that symptoms will return. Two classes of antipsychotic medications--conventional (or typical) and atypical--are used to treat schizophrenia.

Conventional, or typical, antipsychotic medications, such as haloperidol, chlorpromazine, and fluphenazine, are effective in treating the positive symptoms of schizophrenia. These older medications, while effective in treating the symptoms of schizophrenia, have been in existence since the 1950s.  Newer atypical antipsychotic medications, such as paliperidone ER, risperidone, aripiprazole, olanzapine, quetiapine, and ziprasidone, are the most commonly prescribed treatments for schizophrenia. Available in both oral and long and short-acting injectable forms, atypical antipsychotics relieve the positive symptoms and improve the negative and cognitive symptoms of schizophrenia.

What Is the Role of Continuity of Therapy in People With Schizophrenia?

For the millions of Americans who experience schizophrenia or other serious mental illnesses and their family members, one of the most critical periods in an individual's recovery is the transition from intense inpatient (hospital) care settings to community-based services. This "continuity of therapy" is a process involving the orderly, uninterrupted movement of patients among the diverse elements of the service delivery system. Specifically:

When taking into account the complex nature of mental illnesses and the multiplicity of treatments and services that are needed by people in search of recovery, continuity of care and the coordination of treatment and services are important factors in assuring quality mental healthcare.

Given the important role that medications play in allowing for symptom reduction or alleviation, continuity of medication therapy must receive highest priority.

A Vision to Address Continuity of Care and Treatment
In certain environments, systems designed to serve mental health patients and their caregivers experience serious shortcomings when it comes to the level and depth of communication, cooperation, and coordination of treatment and services necessary to avoid service fragmentation and discontinuity.
To address this, the National Council for Community Behavioral Healthcare released recommended new approaches to provide seamless continuity of treatment for people with schizophrenia and other serious mental illness. The National Council consensus statement was prepared by a 24-member panel composed of leading accrediting organizations, hospital and community treatment organizations, patients, family members, researchers, state authorities, and psychiatric leaders. The findings, presented at the 37th Annual National Conference of the organization, focus on breaking down barriers between systems of care. The expert panel developed recommendations that address administrative, professional, and human elements required to ensure complete continuity of care.

Specific recommendations are as follows:

- Encourage collaboration between hospitals and community-based organizations

- Use a quality improvement approach to enhance continuity of therapy by benchmarking a performance and outcomes standards at the organizational level

- Ensure that all patients have a level of care management for the transition from inpatient to community, including reimbursable care management services by all payers

- Focus on the "Pull Model" of transition from inpatient to outpatient care by involving community providers in the transition before patients get discharged

- Align accreditation standards that address and improve continuity of therapy

- Educate patients and their families on the importance of maintaining a personal healthcare history

- Promote more thoughtful use of inpatient services to reduce emergency room use and an eventually decrease the number of hospitalizations

- Share data about mental health services with appropriate organizations in usable and timely ways

- Involve patients and their advocates in all levels of system delivery and evaluation


REFERENCES:

Hazel NA, McDonell MG, Short RA, et al. Impact on multiple-family groups for outpatients with schizophrenia on caregivers' distress and resources. Psychiatric Services. 2004;55:35-41.

McDonell MG, Short RA, Berry CM, Dyck DG. Burden in schizophrenia caregivers: impact of family psychoeducation and awareness of patient suicidality. Family Process. 2003;42:91-103.

National Institute of Mental Health. Schizophrenia. U.S. Department of Health and Human Services. National Institutes of Health. NIH Publication No. 06-3517. Revised July 12, 2006.

Quieting the voices: new treatments for ‘beautiful minds.' Physician's Weekly. April 15, 2002; Vol. XIX, No. 15. Available at: http://www.physiciansweekly.com/article.asp?issueid=15&articleid=57&printable=1. Accessed September 12, 2006.

Schizophrenia facts and statistics. Available at: http://www.schizophrenia.com/szfacts.htm. Accessed September 6, 2006.

Schizophrenia overview. Available at: http://www.healthyplace.com/communities/thought_disorders/site/schizophrenia_ overview.asp. Accessed September 12, 2006.

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What is it? Overview of schizophrenia. Available at: http://www.schizophrenia.com/family/sz.overview.htm. Accessed September 6, 2006.