Treatments for Schizophrenia

Direct effect on dopamine system, we cannot decrease dopamine or reduce number of receptors so the best thing to do is block the receptors.

Conventional antipsychotics

• Bind to dopamine receptors blocking action of dopamine (antagonist).
• Eliminates symptoms, mainly the positive ones.

Atypical antipsychotics

• Only temporarily block dopamine receptors then dissociate to allow normal transmission.
• Also block serotonin receptors
• Fewer side effects and also combat some negative symptoms.

Effectiveness

• Relapse rates - Davis et al - significant difference vs. placebo.
• However, studies like this aren't fair comparison as those on placebo may be in withdrawal state so very sensitive to dopamine - more likely to relapse.
• Davis analysed 29 studies relapse rates 19% vs. 55%, however 45% didn't relapse on placebo - misleading statistics.
• Other factors are important-  one of studies reviewed by Davis concluded that drugs only made a difference for those living with hostility and criticism in environment. In more supportive environments no difference between drugs and placebo.

Appropriateness

• Serious side effects - tardive dyskinesia (uncontrollable facial movements). 30% on drugs experience this and 75% of cases are irreversible.
• Motivational deficits - prescriptions reinforce idea of something being wrong, less motivation to seek psychological help and make changes.
• Compliance of medication - problem especially due to side effects. May not understand need to carry on if symptoms go away.

Effectiveness

• Atypical only slightly better than conventional according to meta analysis.
• Effectiveness with negative symptoms has marginal support, only slightly better.

Appropriateness

• Lower likelihood of tardive dyskinesia, rates of 30% on conventional vs 5% on atypical.
• Fewer side effects - patients more likely to continue with medication.

Ethical issues

• Out-of-court settlement in US awarded to tardive dyskinesia sufferer in line with Human Rights Act. 'No-one shall be subject to inhuman or degrading treatment'.
• Are placebo studies ethical? Is it correct to knowingly give someone no treatment.

In historical times it was thought that schizophrenia could be cured by having seizures. Initial experiments with ECT produced negative results.

The procedure

• Electric current passed through two electrodes placed on forehead and temple (unilateral ECT).
• Patient injected with barbiturate so they're unconcious
• Given a nerve blocking agent to paralyse them (their breathing is aided)
• A small electric current (0.6 amps) passed through brain for half a second, inducing a seizure lasting around a minute which affects entire brain.
• Patient usually requires 3-15 treatments.

• Tharyan & Adams review of 26 studies - compared ECT to placebo conditions. More people improved in ECT condition. No indication advantage maintained from mid-long term. When ECT compared to drugs, drugs preferred. 
• Limited evidence suggesting drugs + ECT was better, this may be appropriate when symptoms need to be relieved quickly.

Effectiveness

• American Psychiatric Association review compared ECT with fake ECT and found results the same as using anti-psychotics.
• Indian study (Sarita et al.) - no difference in symptom reduction when ECT compared with fake ECT.

Appropriateness

• Significant risks including memory dysfunction, brain damage and even death. Use of ECT has declined massively.

Basic assumption of CBT is that people often have distorted beliefs which influence behaviour in maladaptive ways.

• Delusions for example are thought to result from faulty interpretations of events.
• CBT aims to help to patient identify and correct these faulty thoughts.
• Patients encouraged to trace back origins of their symptoms to get better idea of how they developed.
• Patients to dispute their irrational thoughts e.g. test validity by empirical disputing.
• Patients to look for alternative explanations and coping strategies.

Example of a delusional belief:

• Action - overhearring someone say "I know what's on your mind".
• Belief - everyone can read my thoughts.
• Consequence - paranoia, avoid situations with others.

• Drury et al.- 25-50% reduction in recovery time on drugs + CBT. Also reduction in positive symptoms.
• Better patient satisfaction
• Supporting research - Gould et al - All 7 studies in meta analysis reported significant decrease in positive symptoms + less likely to relapse.
• Most studies involve CBT + drugs so we cannot assess effectiveness of CBT alone.
• Who benefits? Not everyone may benefit from CBT. 142 schizophrenic patients studied and many deemed unsuitable for CBT as psychiatrists believed they wouldn't fully engage. Older people less suitable and therapy requires a lot of commitment.
• Combination therapy - American Psychiatric Association recommend supportive interventions such as psychotherapy + CBT. APA are respected and reputable.
• Ethical issues - Research must not put patients at risk (they're vunerable anyway). Potential harm may include use of placebo conditions, medication discontinuation and capacity for informed consent - competent? (MHA)

Psychoanalytic therapy is based on the assumption that individuals are often unaware of the influence of the unconcious conflicts on their psychological state.

• The aim of psychoanalysis is to bring conflicts into concious mind so they can be dealt with.
• All symptoms are meaningful and a product of the patient's history
• Psychoanalyst will first build a relationship with patient, gaining trust (supportive role) before trying to access the unconcious mind and identify repressed conflicts.

Freud believed schizophrenics couldn't be analysed as they were incapable of transferrence - emotions originally associated with one person are unconciously shifted onto analyst.

Examples of psychoanalysis - free association, dream analysis.

• Research support - Gottdiener reviewed 37 studies of over 2500 patients. 66% of those receiving psychotherapy improved compared to 35% of those who didn't receive psychotherapy.
• Key factors - type of psychotherapy, cognitive and psychotherapy had similar success rates, outpatients improved more than inpatients.
• Inconclusive evidence - Schizophrenia Patient Outcome Research Team argued psychotherapy was actually harmful.
• Contradictory findings - May found patients treated with therapy + anti-psychotics had better outcomes than those treated with therapy alone. However anti-psychotics alone were better.
• Combination therapy - American Psychiatric Association recommend supportive interventions such as psychotherapy + CBT. APA are respected and reputable.
• Costs of therapy - expensive, long term, lack of evidence means not worth expense.
• Many patients withdraw
• Therapies difficult due to poor communication of schizophrenics.
• Ethical issues - research shouldn't put patient at harm e.g. by medication discontinuation, placebo conditions, capacity for informed consent - are they competent? (MHA).
• Therapy relies of psychodynamic theory being correct.