1. Discuss several treatment models for schizophrenia.

2. Detail the recovery model for treating schizophrenia.

3. Describe a recovery-oriented approach to medication management in schizophrenia.

4. Compare and contrast the treatment of schizophrenia in the United States and England.

5. Explain why restraint, especially mechanical restraints, should be the choice of last resort in managing patients with schizophrenia.

Is There a Psychopharmacology of Recovery from Schizophrenia?
Peter J. Weiden, MD, Professor of Psychiatry, and Director, Psychotic Disorders Program, Center for Cognitive Medicine, Department of Psychiatry, University of Illinois College of Medicine, Chicago

Medical parallel: treatment of complicated medical illness such as cancer requires clinician to be good strategist and good technician; same applies to complicated psychiatric illness such as schizophrenia

Current challenges in treating severe mental illness: cure unlikely for most patients; more medication choices than ever before, creating more chances to “get it right” but also more chances to “get it wrong”; optimism that better outcomes can be achieved; controversy about degree to which newer medications can improve outcome; newer antipsychotic medications still have burden of side effects, but burden different from that of older antipsychotics (eg, newer antipsychotics have reduced neurologic burden but increased metabolic burden)

Treatment models in schizophrenia: phase-of-illness model has goal of keeping patient stable and avoiding relapse; in hierarchical model, treatment progresses in linear fashion, from stabilizing patient to reducing burden of treatment and/or burden of disease to recovery (no consensus on what constitutes recovery in schizophrenia; clinician, patient and family, and insurance company may have widely differing definitions)

Treatment goals in schizophrenia: remission—concept derived from treatment of affective disorders, in which it means patient has no symptoms; in schizophrenia, it means symptoms may be present but do not interfere with patient’s functioning or quality of life; recovery—defined by President’s New Freedom Commission on Mental Health as “process in which people are able to live, work, learn, and participate fully in their communities; for some individuals, recovery is the ability to live a fulfilling and productive life despite a disability”; ie, patient may experience symptoms but still lead full productive life

Recovery model in schizophrenia: key assumptions—deterioration not inevitable; achieving stability marks beginning, not end, of long-term treatment; goals calibrated toward achieving individual’s health rather than comparing him or her to others with persistent illness; specific goals are chosen by patient, not by family or clinician

Reasons recovery-oriented treatment realistic in schizophrenia: ascendancy of neurodevelopmental model over neurodegenerative model; evidence for continued improvement over and above stabilization with newer medications; evidence that psychosocial interventions can reduce persistent symptoms; consistency of differences of side-effect profiles across antipsychotic treatment options

Recovery-oriented approach to medication management: ask patient about his or her goals and frustrations; match frustrations with target symptom that can be treated and work with patient to identify priority symptom to be treated; advise patient not to stop medications

Persistent positive symptoms: optimize current medication regimen before changing medications; anticholinergics attenuate response to antipsychotics; antidepressants delay or attenuate response to antipsychotics; rule out nonpharmacologic causes of poor treatment response

Cognition: news mixed; Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study showed that newer antipsychotics have limited benefits on cognition, relative to older antipsychotics; anticholinergic estimated to account for ≈50% of cognitive dysfunction in patients taking anticholinergic; when asked which symptoms most frustrating, most patients say cognitive symptoms and affective symptoms trump positive symptoms and negative symptoms; first consideration is not to make cognitive symptoms worse

Depression: newer antipsychotics better for attenuating comorbid depression; if depression continues, consider whether antidepressant or psychosocial intervention better adjunct, remembering that antidepressants can aggravate psychosis in some patients

Adverse events and burden of treatment: theoretically, antipsychotic response can be achieved without side effects; difficult and requires good strategy; extrapyramidal side effects and sedation not necessary components of treatment; in formulating treatment plan, clinician must assess patient’s level of distress and risks of treatment modalities

A Patient’s Perspective on Schizophrenia
Elyn R. Saks, MLitt, JD, Associate Dean of Research and Orrin B. Evans Professor of Law, Psychology, and Psychiatry and the Behavioral Sciences, University of Southern California Gould School of Law, Los Angeles; Adjunct Professor of Psychiatry, University of California, San Diego, School of Medicine

Introduction: in childhood, speaker experienced phobias, obsessions, and night terrors; first episode of disorganization occurred at 5 or 6 yr of age; first frankly psychotic experience occurred in high school, when patient thought houses were talking to her; no overt psychotic episodes in undergraduate college, “but there were portents of my illness even then my first and senior years I had several out-of-control episodes, which resolved themselves but were kind of frightening”

“Officially mentally ill”: speaker attended graduate school at Oxford University in England, “and there my world really started falling apart”; initially, problem seemed to be depression with mild paranoid features, but over time “developed into a thought disorder vs a mood disorder”; speaker lost weight, became socially isolated, and found herself unable to work; began having “vivid fantasies” of hurting herself because “that was all I was worthy of”; general practitioner referred her to psychiatric hospital, where her first psychiatric hospitalization occurred; high school experience with drug treatment program made her resistant to taking drugs, but she eventually agreed to take medications because she was not getting better without them

Treatment in England: speaker resolved that first hospitalization would be last, but was readmitted 8 mo later; during second hospitalization, perceived command hallucinations telling her to do various things, but origin of commands unclear; nevertheless, “it never occurred to me that disobedience was an option”; commands told her to inflict pain on herself, which she did by burning herself with various media; hospital staff knew of burns and treated them but did not overreact to patient’s behavior; hospitalization continued for 4 mo with no improvement, so speaker was referred to psychoanalyst, and “I felt for the first time heard”; in contrast to hospital physicians who recommended that speaker quit school and return to United States, psychoanalyst recommended she stay at Oxford and continue to work since “it [work] gives you purpose; it challenges you”; he also recommended she remain in psychoanalysis and referred her to another psychoanalyst for long-term treatment

Psychoanalysis: speaker initially afraid of psychoanalyst, but also afraid of losing her; leaving psychoanalyst to return to United States was difficult but finally accomplished

Treatment in United States: on returning to United States, Ms. Saks enrolled in Yale Law School, but without psychoanalyst “started spinning more and more out of control”; initially, speaker did well academically, but soon was unable to work; admitted to Yale infirmary for one weekend, but dismissed as “too difficult to manage”; “major and public” breakdown occurred during second week of first semester at Yale Law School, discomfiting some classmates and causing them to leave; professor took her to emergency department at Yale Medical Center, and admitting psychiatrist recommended hospitalization; patient revealed that she had nails in her hand, which she refused to surrender; nails were forcibly taken away and patient placed in restraints, despite her pleas to be released; restraints continued over many weeks; patient estimates that first few days she was in restraints for 20 of every 24 hr; following weeks, she was in restraints for 8 to 20 hr/day; then transferred to different ward and restraints discontinued; she was chagrined to find that use of restraints “has more to do with the ethos of the ward you happen to be on than the kind of patient or patient/staff ratio”; in addition, she was forcibly medicated at times and allowed little privacy; during entire stay, Ms. Saks was never allowed to speak to anyone, including family, without staff present

Bottom line: after these experiences, speaker prefers British “benign neglect” approach to American “overintervention,” saying she is “very pro-psychiatry but very anti-force”

Next chapter: while at Yale, speaker found local psychoanalyst and finished law school in 3 yr; after graduation from law school, she took local jobs to remain close to and continue treatment with same psychoanalyst; worst psychotic episode occurred when psychoanalyst announced his retirement; he reversed his decision and continued to treat Ms. Saks for another 1.5 yr, preventing, in speaker’s opinion, another hospitalization

Treatment in Southern California: Ms. Saks accepted position at University of Southern California Gould School of Law in Los Angeles and, on arrival, immediately contacted psychoanalyst who had been resident under one of her previous analysts and who knew her; she decided unilaterally to try to get off medication and began tapering it and seeing psychologist in addition to psychoanalyst, but relapsed into psychosis; this experience helped to overcome speaker’s denial of having serious mental illness; she was further convinced by change of medication from typical antipsychotic to olanzapine, which “worked really, really well for me in the beginning, for several years”; over time, however, dose had to be escalated and she still experienced breakthrough symptoms, and was therefore switched to clozapine; “the change was fast and dramatic the clinical result was like daylight dawning after a long night”; speaker no longer felt “pushed around” by her illness and was convinced “once and for all that I actually had a real illness”

Post-tenure life: with symptoms well controlled, speaker earned Philosophiac Doctor (PhD) in psychoanalysis and treated several patients until her book (The Center Cannot Hold) was published in 2007, stopping only because she felt publication of book for general audience overly complicated patient-analyst relationship

Patient’s observations and suggestions: speaker does not wish to be seen as regretting life she could have had if she had not been ill; rather, “the humanity we all share is more important than the mental illness we may not”

First point: with proper treatment, person with mental illness can lead full and rich life; “for the person with mental illness, the challenge is to find the life that’s right for you; but in truth, isn’t that the challenge for all of us, mentally ill or not?” patient recommends that more resources be devoted to treating those who do not have financial wherewithal to receive level of care that she did

Second point: psychoanalysis can be helpful for some people with psychosis, “even though it’s not supposed to be helpful”; patient thinks psychoanalysis essential to her recovery and to her ongoing ability to function; she recommends that low-fee clinics at institutions explore this treatment further

Third point: use of force destructive; patient felt being restrained and forced to take medication aversive, painful, and degrading; using force not “a stable solution,” because once force no longer imposed, patient has no incentive to discontinue behavior that caused caretakers to use force in first place; “there may have been times since my last hospitalization where it would have been good and safe and beneficial for me to be in the hospital, but my memories are so horrible I would never go to a hospital again if I can possibly avoid it”; she recommends noncoercive ways to get patients to want treatment

Fourth point: mechanical restraints painful and degrading; restraints did not make speaker feel safe, but helpless and ashamed; literature shows that every week, 1 to 3 patients in United States dies in restraints