Management of schizophrenia

Clinical assessment

The differential diagnoses shown in Figure 1 should be excluded by history and mental state examination, and by interviewing informants. If there is any suggestion of a drug-induced psychosis a urinary drug screen should be carried out. Apart from this, only those investigations suggested by the history and examination are likely to reveal abnormalities relevant to the diagnosis. There are two exceptions to this. In cases with an unusual presentation, such as onset in middle age, organic causes should be actively investigated. In cases which do not respond to treatment, the diagnosis should be reviewed and a wider range of investigations carried out.

Fig. 1 Differential diagnosis of positive and negative symptoms of schizophrenia.

It is important to assess whether inpatient treatment is required. This will depend on a number of factors including the severity of symptoms and their effect on carers, the level of support the patient has in the community, the patient’s insight, the likelihood of them sticking to the advised treatment, and an assessment of risk to themselves or others. The majority of acute episodes can now be managed in the community with input from specialist teams such as CRHT, EIP and AOT (see p. 5). Chronic schizophrenia is usually managed in the community, sometimes after a period of rehabilitation as an inpatient. A small number of patients require long-term care in hospital or in 24-hour nurse-staffed community hostels.

Drug treatment

Acute treatment

The standard treatment of schizophrenia is with antipsychotic drugs (see p. 24). In drug trials of antipsychotics in acute schizophrenia, up to three-quarters of patients receiving active treatment improve, with this improvement usually beginning after 2–3 weeks. Of patients receiving placebo medication, a small proportion will improve but most will either stay the same or get worse. Antipsychotic drugs are particularly effective in reducing positive symptoms.

Most of the commonly used antipsychotics are equally effective. The important exception is clozapine, which often reduces positive symptoms that have proved resistant to treatment with other antipsychotics. Negative symptoms are usually unaffected by antipsychotic drugs. If they appear to get worse, it is probably because the sedative and Parkinsonian effects of the antipsychotic are being mistaken for negative symptoms. If they appear to improve, it is probably because the patient is less distracted by positive symptoms. There is some evidence that the atypical antipsychotics have a direct effect on negative symptoms but this remains controversial.

Antipsychotics are usually given orally for the treatment of acute schizophrenia. Until recently, atypical antipsychotics were the usual treatment of choice, because of their lower propensity to cause movement side effects. However, the metabolic effects of these drugs, particularly weight gain and diabetes mellitus, have prompted a re-evaluation. The atypicals are still the most commonly prescribed drugs but conventional antipsychotics are coming back into favour. As the different drugs are equally likely to be effective, apart from clozapine, decisions about which drug to use should be based on their likely side effects. For instance, more sedative drugs may be preferred for a patient who is sleeping poorly or is very distressed or anxious, but not for one whose job involves driving motor vehicles.