World Mental Health Day - Living with Schizophrenia

The theme of this year's World Mental Health Day - which takes place on 10 October is’ “shines a light on schizophrenia”. 

Schizophrenia is a disorder of brain function, affecting thoughts, feeling and acts of an individual.  Symptoms develop either progressively or appear abruptly and vary from one patient to another. The disease evolves in cycles of remission and relapses. Over time, slow decline in mental function and social relationships occurs. This leads to a marked personality change, social isolation, occupational disability, cognitive impairment and poor health.  An estimated of around 1% population suffers from schizophrenia mostly in the age group of 15-35 years. According to a World Health Organization estimate, schizophrenia was the 5^th leading worldwide cause of global disease burden in the last decade with years lived with disability (YLD) among males (2.8%) and in females (2.6%).  

Many factors are considered as possible cause of schizophrenia which includes, genes, environment, different brain chemistry and structure etc. Figure 1 summarizes the possible etiology of schizophrenia.

Figure 1. Etiology of schizophrenia

Source: Zubin and Spring, 1977

Schizophrenia has emerged as a financial burden on society because of the potential for institutionalization and chronic use of treatments. A study in United States of America on economical burden per patient towards criminal justice and psychiatric hospitalization cost has put the cumulative three-year costs to the state government at $21,146,000 for criminal justice and $25,616,000 for hospitalization costs of patients (respectively $3,984 per patient and $4,827 per patient). A relative 20% increase in the proportion of patients receiving antipsychotic treatment following release from incarceration has decreased total cumulative costs over three years by $1,871,100 ($353 per patient).

Schizophrenia has associated humanistic burden which concerns patients, but also caregivers, relatives, neighbors and other individuals in a patient’s daily life.  In most of the developing countries, individuals with schizophrenia live with their families; family burden is an important component of the impact of the illness on the community that should be included in measures of the relative social and economic importance of the condition. Even after symptoms subside, patient’s disability is independently associated with family burden. It is important to target both symptoms and disability in treatment strategies for this severe, often lifelong, condition.

Early signs and symptoms

In many persons, schizophrenia appears suddenly and without warning, but in most of the cases it comes down slowly with warning signs and gradual decline in functioning. The most common early warning signs of schizophrenia includes.

• Social withdrawal
• Hostility and suspiciousness
• Deterioration of personal hygiene
• Flat, expressionless gaze
• Inability to cry or express joy; Inappropriate laughter or crying
• Depression
• Oversleeping or insomnia
• Odd or irrational statements, strange use of words
• Forgetful; unable to concentrate
• Extreme reaction to criticism

Common Symptoms

There are two categories of symptoms

1. Positive symptoms – are disturbances added to the personality of an individual and usually respond well to medication that may include delusions, disordered thought and speech, tactile auditory, visual, olfactory and gustatory hallucinations.
2. Negative symptoms- are the capabilities that are lost from the individual’s personality and do not respond to medication, includes, social withdrawal, extreme apathy, lack of drive or motivation and emotional unresponsiveness.

Diagnosis

Diagnosis of schizophrenia is based on a full psychiatric evaluation, medical history, physical examination and laboratory tests.

Psychiatric evaluation: The doctor or psychiatrist asks a series of questions which can cover family life psychiatric history and family history of mental health problems.

Medical history and exam: Doctor may ask and evaluate personal and family health histoy. A complete physical examination is required for medical issues that could be causing or contributing to the problem.

The following criteria are used for confirmation of schizophrenia: The presence of two or more of the following symptoms for at least 30 days may be a case of schizophrenia- 1.      Hallucinations 2.      Delusions 3.      Disorganized speech 4.      Disorganized or catatonic behavior 5.      Negative symptoms (emotional flatness, apathy, lack of speech) Significant problems in functioning at work or school, relating to other people and taking care of oneself. Continuous signs of schizophrenia for at least 6 months, with active symptoms (hallucinations, delusions, etc.) for at least 1 month. No other mental health disorder, medical issue, or substance abuse problem is causing the symptoms. Differential diagnosis of schizophrenia covers, psychotic disorders such as schizoaffective disorder, schizophreniform disorder and brief psychotic disorder resembles schizophrenia. Additionally, some substance abuse like alcohol, heroin, amphetamines and cocaines may also triggers psychotic symptoms resembling schizophrenia.

Laboratory Tests: While there are no specific laboratory tests that can diagnose schizophrenia, simple blood and urine tests can rule out other medical causes of symptoms. Brain-imaging studies, such as MRI or a CT scan, may also be prescribed in order to look for brain abnormalities associated with schizophrenia.

Types of Schizophrenia

Schizophrenia is categorized into different types based on different symptoms in an indivisual

• Paranoid schizophrenia – in this type a person feels extremely suspicious, persecuted, or grandiose, or experiences a combination of these emotions.
• Disorganized schizophrenia – individual often shows incoherent speech and thought, but may not have delusions.
• Catatonic Schizophrenia – catatonia is now a days not related to schizophrenia, but patients in this category is withdrawn, mute, negative and often assumes very unusual body positions.
• Residual schizophrenia – in this condition a person may no longer experience delusions or hallucinations, but has no motivation or interest in life.
• Schizoaffective disorder- a person has symptoms of both schizophrenia and a major mood disorder such as depression.
• Post-schizophrenic depression – a phase of depression arising after a schizophrenic illness where some low level schizophrenic symptoms persists.
• Simple schizophrenia – In this type a progressive development of prominent negative symptoms occurs in patients with no history of psychotic episodes.

Red Flag Signs ·      Overall mortality rate due to schizophrenia has been estimated two to three times high as for general people. ·      Most dangerous aspect associated with schizophrenia is the violent behavior of the patient. ·      In this condition the patient can grievously harm him/herself and also any person in surrounding including family members and caregivers. ·      Suicidal behavior in schizophrenic patients has remained the biggest risk. ·      Around 4-13% of patients with schizophrenia attempt suicide which is many times higher than normal population. ·      Suicide is not the only cause of higher mortality in schizophrenic patients but obesity, cardiovascular diseases also play a significant role. ·      Reduced activity and movement the patient gains weight which also puts him at risk of developing metabolic disease. ·      Criminal victimization has been reported to be most frequently associated with alcohol and/or illicit drug use/abuse, homelessness and engagement in criminal activity.

Management

It is still hard to pin point on the exact cause of schizophrenia, making hard the complete treatment of the disease. Till date no cure is available for schizophrenia. In the current time management of schizophrenia includes treatments which focus on eliminating symptoms of the disease. The treatment methodologies include antipsychotic medications and various psychosocial treatments.

Antipsychotic medications

These medicines are available for more half of the century. The older types are called conventional or typical antipsychotics. These medicines can reduce the positive symptoms of schizophrenia in about 7-14 days. Antipsychotics have no significant effect on reducing the negative symptoms and cognitive dysfunction. Patients using antipsychotics continuously have a decreased risk of relapse. The benefits of antipsychotic drugs become inconsistent beyond three years of their continuous use.

Some of the commonly used effective antipsychotic drugs are -

• Clozapine
• Amisulpride
• Olanzapine
• Rispoeridone
• Quetiapine
• Ziprasidone
• Aripiprazole
• Paliperidone

These drugs give good response in 40-50% patients and in 30-40% patients it gives partial response, making these drugs a frontline treatment option in newly diagnosed cases. Resistance to these drugs can be observed after 6 weeks of treatment, either alone or in combination with other psychotic drugs. The side effects associated with these drugs includes weight gain, diabetes and metabolic disorders. These drugs are contraindicated in pregnancy and women of child bearing age.

Psychosocial therapy

The second line of treatment most commonly used for schizophrenia is psychosocial therapy. These treatments are most effective for patients who are already stabilized on antipsychotic medication. The psychosocial treatment helps these patients to deal with everyday challenges and hardships associated with the ailment such as difficulty in communication, self care, work and forming and keeping relationships. Patients on psychosocial therapy are regular in taking their oral medications making them less vulnerable to relapse and hospitalization for violent episode. The therapist can provide education about the disorder, common symptoms or problems patients may experience and the importance of staying on medication.

The psychosocial therapy may also help the patient in –

-          Illness management skills by providing knowledge

-          Integrated treatment for co-occurring substance abuse, if any.

-          Rehabilitation of the patients including boosting the confidence and vocational training

-          Family education i.e. training to the family members or care givers to efficiently manage and care of  the affected person post-hospital discharge

-          Cognitive behavioral therapy is a type of psychotherapy which focuses on thinking and behavior. It helps to tackle with those symptoms which are hard to eradicate using drugs.

Ultimately the support of family and peers is very important to build up confidence in patients after oral medications therapy and reduction of psychotic symptoms. There help and support can make the rehabilitation easy and reduce the cases of relapse and chances of further hospitalization.

Prevention of schizophrenia

Preventing schizophrenia before it appears is still under intensive early stages of research. There are some positive signs observed which can provide clue on preventing schizophrenia ad lowering the risk. Currently two approaches are under investigation for prevention of schizophrenia.

1. Preventive measures taken prior to any measurable signs and symptoms of early phase (prodormal phase) of schizophrenia .
2. Preventive measures taken during the prodormal period of schizophrenia, where patient starts showing early signs of the condition.

Genetic factors are thought to be associated with development of schizophrenia. Preventing close marriages for prevention of expression of defective genes may play a significant role in people with family history of schizophrenia. Environmental factors have been identified as culprit of increasing the risk of schizophrenia. Environmental factors may include everything from the nutritional environment or viruses to social environment growing up to teen drug use or stress. Curbing these factors may significantly decrease the risk of schizophrenia.

Methods for awareness

Awareness about the disease is the key to early diagnosis and proper management of the patients. A delay in identification of symptoms and proper care risks the aggravation of the condition. High risk group people such as person with family history of schizophrenia, using drugs/substance of abuse, stressed workers and smokers may be made aware of the risk factors associated with their behavior.

Families and peers of affected person may also be made aware and asked to follow the coping guidelines to properly take care of the patient. Some of points of coping guidelines are as follows:

1. A daily routine for the patient should be established
2. Educate and try to help the patient to stay on medication
3. Discuss about problems or fears the patient may have
4. Understand about the emotionally and physically exhaustive care of patient
5. Keep communications simple and brief when communicating with patient.
6. Be patient and calm
7. Ask for help if needed; join a support group.

Showing love and support for the patient is the key for managing schizophrenia and awareness along with proper therapy may improve the life and reduce the risks of deterioration of the patient’s condition.

References:

1.      Millier A, Schmidt U, Angermeyer MC, Chauhan D, Murthy V, Toumi M, Cadi-Soussi N. Humanistic burden in schizophrenia: aliterature review. J Psych Res. 2014; 54:85-93.

2.      Van Os J, Kapur S. Schizophrenia. The Lancet.2009; 374(9690):635-645.

3.     Lin I, Muser E, Munsell M, Benson C, Menzin J. Economic Impact of Psychiatric Relapse and Recidivism among Adults with Schizophrenia Recently Released from Incarceration: A Markov Model Analysis. J Med Econ. 2014; 30:1-29.

4.     Zhang Z, Deng H, Chen Y, Li S, Zhou Q, Lai H, Liu L, Liu L, Shen W.Cross-sectional survey of the relationship of symptomatology, disability and family burden among patients with schizophrenia in Sichuan, China. Shanghai Arch Psychiatry. 2014;26(1):22-29.

5.      Leucht S, Burkard T, Henderson J, Maj M, Sartorius N. Physical illness and schizophrenia: a review of the literature. Acta Psychiatr Scand.2007;116(5):317e -333.

6.      Zubin J, Spring B. Vulnerability: A new view of schizophrenia. J Abnormal Psychol.1977;86(2):103-126.

7 Mental Health America. Schizophrenia. http://www.mentalhealthamerica.net/conditions/schizophrenia Accessed October 9, 2014.

8. National Institute of Mental Health, USA. Schizophrenia.  http://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml#part5 Accessed October 9, 2014.

9.      Maniglio R. Severe mental illness and criminal victimization: a systemic review. Acta Psychiatrica Scandinavica. 2009; 119(3):180-191.

10.  Smith T, Weston C, Lieberman J. Schizophrenia (maintenance treatment). Am Fam Physician. 2010; 82 (4): 338–339.

11.  Harrow M, Jobe TH. Does long-term treatment of dchizophrenia with antipsychotic medications facilitate recovery?. Schizophrenia bulletin. 2013;39(5):962–965.

12.  Preventing schizophrenia - recent research. Schizophrenia.com . http://schizophrenia.com/prevent.htm   Accessed October 9, 2014.