Running Head: Treatment of Schizophrenia



Running Head: Treatment of Schizophrenia

The Treatment of Schizophrenia: A Literature Review

Olivia Currin

Wake Forest University

Abstract

Schizophrenia falls under Schizophrenia Spectrum and Other Psychotic Disorders in the DSM-V. According to the World Health Organization (2013), Schizophrenia a treatable disorder affecting 24 million people worldwide. The incidence rate is low but the prevalence is high due to the chronicity of the disorder (WHO, 2013). Prevalence rate of schizophrenia is high for several reasons such as, substance abuse and lack of compliance with treatments. Schizophrenia has a high prevalence of comorbidity with substance abuse disorders (Thoma & Daum, 2013). There are several theories explaining the high prevalence of drug abuse in individuals with schizophrenia including; drug usage prior to diagnosis, self-medication to counteract the prescribed drugs side effects or low cognitive abilities (Thoma & Daum, 2013). These reasons lead into lack of compliance with treatments, which this literature review will focus. More than 50% of individuals are not receiving appropriate care and 90% of untreated individuals with schizophrenia are in developing countries (WHO, 2013). There are several factors that contribute to an individual’s lack of compliance with treatment. Throughout this literature review, there have been many sources that have given a variety of reasons for non-compliance with treatment, including a person’s self-esteem, cognitive ability, dissatisfaction with prescribed medication and even lack of family support related to the success of their treatment adherence. Several studies have explored family therapy, cognitive behavioral therapy, and peer interventions as successful treatment methods for individuals with schizophrenia. This review will provide an overview of treatment options available to individuals with schizophrenia with minimal medical intervention. Further exploring the recovery model of treatment to increase individual’s treatment compliance.

Literature Review of Treatment of Schizophrenia

Schizophrenia is a “serious mental illness characterized by incoherent or illogical thoughts, bizarre behavior and speech, and delusions or hallucinations, such as hearing voices. Schizophrenia typically begins in early adulthood, emerging late teens through mid 30s” (American Psychiatric Association, 2013). Based on several studies, the incidence and prevalence seems to be equal in men and women. The age of onset and first episode typically occurs between the age of 15 and 35; men’s symptoms are documented to appear earlier than women’s symptoms (WHO, 2013; El-Missiry, Aboraya, Manseur, France & Border, 2009). According to the DSM-V (APA, 2013), “the general incidence of schizophrenia tends to be slightly lower in females, particularly among treated cases”(p.103). The gender issue is seen to be controversial and undetermined, El-Missiry, et al, mentions several studies completed in the 1980s reporting overall, “that male patients have earlier onset, more negative symptoms, more cognitive deficits, poorer premorbid functioning and poorer response to antipsychotic medications”(p.45).

“Despite treatment advances over the past decades, schizophrenia remains one of the most severe psychiatric disorders that is associated with a chronic relapsing course and marked functional impairment in a substantial proportion of patients” (Kane & Correll, 2010). Treatment approaches need to consider several factors that contribute to an individuals compliance such as, “ patient’s current symptoms, comorbid conditions, past therapeutic response, and adverse effects, as well as patient choice and expectations”(Kane & Correll, 2010). Relating, to the most common comorbid condition, the prevalence of alcohol and drug abuse is very high in individuals with schizophrenia, 47% of individuals with schizophrenia have had a substance abuse disorder (El-Missiry, et al., 2009). This prevalence is four times higher than the prevalence of drug use in non-schizophrenic population (El-Missiry, et al., 2009). Schizophrenia patients experience additional significant comorbity with anxiety disorders, obsessive-compulsive disorder and panic disorder (APA, 2013, p.105). Comorbitiy knowledge is significant in treating schizophrenia patients; comorbity influences will not be the focus of this literature review. This information is important to mention to set the stage for factors of non-compliance but will not be mentioned in depth. This review will look more closely at effective treatment options focusing on reduction of symptoms and compliance adherence. The review is interested in the advances with therapeutic counseling treatment options with minimal medical management.

Methods

My research search began with the CNS 721 website page to assist with the research process through Z Smith Reynolds Library website. I watched the PsycINFO tutorial to help with suggestions on the best way to search the database through the thesaurus. I started with PsycINFO, using “schizophrenia” through the thesaurus as a search term and checked the “major concept” to ensure schizophrenia would be the focus of the articles. I then narrowed my search by adding AND “treatments” through the thesaurus search. I used the thesaurus to ‘explode’ the term “treatment” and was able to pick out specific treatment options such as “cognitive techniques”, “counseling”, “treatment compliance” and “treatment planning”. I narrowed the article publication time frame from 2000 to present. I looked through these articles and got a better idea of what kinds of treatments with minimal medications was being studied. I then further narrowed my search to “schizophrenia” AND a specific therapy; after finding research related to Cognitive Behavioral therapy, Psychosocial treatments, peer interventions and family involved therapy. I collected my articles from PsycINFO and PubMed. PsycINFO provided a PDF file of the article or linked me to the full text through ejournals. I found a book, An Introduction to Marriage and Family Therapy that had a relevant chapter. I loaned this book through Z Smith Reynolds library using the interlibrary loan office. I found that PsycINFO provided the most helpful and accessible information.

Results

Diagnosis

Schizophrenia spectrum and other psychotic disorders include, schizophrenia, schizotypal (personality disorder and other psychotic disorders (American Psychiatric Association, 2013). The DSM-V (American Psychiatric Association, 2013) diagnostic criteria for schizophrenia:

A. Two or more of the following, each present for a significant portion of time during a 1-month period. At least one of these must be (1), (2), or (3):

1. Delusions

2. Hallucinations

3. Disorganized Speech (e.g. frequent derailment or incoherence)

4. Grossly disorganized or catatonic behavior

5. Negative symptoms (i.e., diminished emotional expression or avolition)

B. For a significant portion of time since the onset of the disturbance, level of functioning in one or more major areas such as, work, interpersonal relations or self-care is markedly below the level achieved prior to onset

C. Continuous signs of disturbance persist for at least 6 months. (American Psychiatric Association, 2013, p. 99)

The characteristic symptoms of schizophrenia involve a range of cognitive, behavioral, and emotional dysfunctions, but no single symptom is pathognomonic of the disorder (American Psychiatry Association, 2013, p. 100). There are positive symptoms that include “delusions, hallucinations, disorganized speech and grossly disorganized or rigid behavioral response”(Hecker & Wechler, Ed., 2003). Negative symptoms consist of “restrictions in the range and intensity of emotional expression, in the fluency and productivity of thought and speech and in the initiation of goal-directed behavior”(Hecker & Wechler, Ed., 2003). After a person’s first episode they are usually hospitalized to officially diagnosis an individual and began medication to assist with reducing severity of symptoms.

The Recovery Movement was initiated in the 1990s, treatment of schizophrenia has moved towards less hospitalization and more incorporation of recovery-models of care (Peebles, Mabe, Davidson, Fricks, Buckley & Fenley, 2007). This model is more closely relying on community care for the recovery process. The recovery model continues to be researched and introduced into the mental health world but this does not mean that all mentally ill individuals will be interested or comply with new treatments. 72.1% of mentally ill individuals do not seek professional help because they wish to solve their problems independently or 60.6% of individuals believe that their issues will resolve over time (Peebles, 2007). These statistics relate back to the specific prevalence rate of individuals with schizophrenia and the reasons for non-compliance with treatments. “Patients often do not adhere to existing pharmacological and psychological treatments and even when they do, currently available treatments have an only limited effect. This applies in particular to negative symptoms, which are frequently associated with poor long-term outcomes” (Kane & Correll, 2010).

The recovery model is looking more closely at an individuals overall health through a reduction of symptoms and the individual’s overall well-being. Traditional treatment approaches in the past for “individuals with schizophrenia have had some success in the remission of symptoms, but relatively little has been gained in the individual’s overall wellness, life goals, strengths, aspirations, preferences, personal growth, quality of life, empowerment, and personhood”(Ahmed, Doane, Mabe, Buckley, Birgenheir & Goodrum, 2012). The individuals overall wellness relates to their compliance with treatment options. These factors will be further discussed in relation to effective schizophrenia treatments.

A three phase-model of treatment has been recommended; initial hospitalization, outpatient recovery and then maintaining a stable state (Hecker & Wetchler, Ed, 2003). This three-phase model treatment of schizophrenia consists of “medication during the acute phase in the hospital, the use of pharmacological and psychosocial therapy to provide stabilization during the outpatient period, and the maintenance of a stable state though ongoing multi-modal treatments” (Hecker & Wetchler, Ed, 2003). The “multi-modal treatments” include a variety of different treatment options embracing the recovery model including; cognitive behavioral therapy, peer interventions, family therapy and various other psychosocial/psychotherapy treatments.

Psychosocial and Psychological Treatments. Psychosocial and psychological treatments have been “available for nearly 40 years but their uptake has been poor. A study found that only a third (36.5%) of people with a psychotic illness had participated in any community rehabilitation or day programs over 12 months”(Harris & Boyce, 2013). These treatments tend to incorporate both positive and negative symptoms as well as an individual’s cognitive functioning to assist them with maintaining a stable state (Harris & Boyce, 2013). The reduction of positive symptoms is important but “negative and cognitive symptoms limit the ability of the individual to form relationships, obtain employment, be financially secure and care for themselves independently”(Harris & Boyce, 2013). Psychosocial and psychological treatment umbrellas a variety of different therapeutic approaches. Psychosocial and Psychological Treatments include therapeutic interventions such as:

“Cognitive behavioral therapy for psychosis benefit in the treatment of so-called ‘treatment resistant’ hallucinations or delusions and family therapy has long been acknowledged to be useful in reducing relapse rates in schizophrenia. Even a simple intervention such as psychoeducation reduces the need for readmission and emergency care” (Harris & Boyce, 2013).

Cognitive Behavioral therapy, peer/group interventions and family therapy will be further discussed and effectiveness of treatment options will be addressed. Now to mention, studies that incorporate multiple psychosocial or psychological treatments and new studies that are incorporating new treatment methods.

Effectiveness. A study was completed that addressed two important aspects of schizophrenia treatment, self-stigma and treatment compliance. This study included 105 participants with schizophrenia that were recruited from psychiatric day programs or community settings (Tsang, Fung, & Chung, 2010). The main focus of the study was to determine the relationship between self-stigma, readiness for change and psychosocial treatment adherence. The intervention consisted of, all participants receiving “psychosocial treatment such as vocational rehabilitation programs (e.g., supported employment, sheltered workshop training, and pre-vocational training), social skills training, cognitive behavioral therapy, and family intervention”(Tsang, et al., 2010). Participants completed several questionnaires prior to and after the study to measure results (Tsang, et al., 2010). Five questionnaires were used to collect results such as, Psychosocial Treatment Compliance Scale, Brief Psychiatric Rating Scale, and The Chinese Self-stigma of Mental Illness Scale (Tsang, et al., 2010). The results show that the “correlational analysis suggested that less severe psychiatric symptoms, better global functioning, and better insight toward the beneficial effects of medication were significantly associated with better treatment participation and attendance among the participants” (Tsang, et al., 2010). Relating more specifically to self-stigma showed that “positive life experiences in employment and interpersonal relationships will improve their self-esteem and fight against their self-stigma” (Tsang, et al., 2010).

Psychological treatments are breaking new ground with computer-assisted treatments to focus on improving a patients cognitive functioning (Garrido et al., 2013). In addition, to studies looking at Body Psychotherapy (Priebe et al., 2013) and treatments related to memory (Lett, Voineskos, Kennedy, Levine, & Daskalakis, 2013). These studies are very recent and appear to have very inconclusive results. The studies are not worth mentioning in depth but to mention the new studies being explored to assist schizophrenia patients with improving self-esteem, self-stigma and cognitive functioning to improve their quality of life (Garrido et al., 2013; Priebe et al., 2013; Lett et al., 2013).

Cognitive Behavioral Therapy. Cognitive behavioral therapy (CBT) makes connections “between the person’s feelings and patterns of thinking that underpin their distress” (Jones, Hacker, Cormac, Meaden & Irving, 2012). Jones et al. (2012) mentions that there are a variety of interventions label under CBT. Many studies have incorporated additional active therapeutic elements into treatment with evidence of only an increase in effective results (Jones et al., 2012; Newton-Howes & Wood, 2013). Comparison studies have been conducted by Jones et al. (2012) and Newton-Howes and Wood (2013) to show that there is no significance difference in CBT effectiveness compared with other psychosocial treatment’s effectiveness. Still, CBT continues to be an effective and growing treatment option for individuals with schizophrenia (Jones et al., 2012; Newton-Howes & Wood, 2013).

Effectiveness. The study to mention took a previous study, three trials studying CBT and measured the continued effectiveness in a two-year follow-up (Tarrier, Kinneym, McCathry, Humphreys, Wittkowski & Morris, 2000). The three trials focused in different ways on CBT with routine care versus routine care alone as well as supportive counseling with routine care (Tarrier et al., 2000). The initial results showed significantly less positive and negative symptoms with CBT and supportive counseling compared with routine care alone (Tarrier et al., 2000). Tarrier et al.(2000) assessed the available participants from the original treatment two years later to measure the effectiveness of CBT. 85% of participants from the original treatment phase participated in the follow-up study (Tarrier et al., 2000). The three groups of participants, CBT plus routine care, supportive counseling plus routine care and the third, solely routine care received assessments to measure positive symptoms, negative symptoms and relapses/rehospitalization (Tarrier et al., 2000). The follow-up assessments determined continued significant improvement in positive and negative symptoms in the CBT and supportive counseling plus routine care groups compared with individuals that received routine care alone (Tarrier et al., 2000). There was no significant different between CBT and supportive counseling groups (Tarrier et al., 2000). This study shows the importance of a psychosocial or psychological treatment in addition to routine care makes a considerable difference in a schizophrenia patient’s symptoms and quality of life.

Peer Interventions. Peer interventions are emerging treatments such as, peer-led interventions or peer/group interventions. Peer-led interventions focus on strengthening and emphasizing individuals strengths and abilities instead of their disability (Ahmed et al., 2012). Peer-led interventions “have created opportunities for people living with mental illness to encourage, support, model, empower, and learn from each other in ways that were not possible under the hospice of traditional care”(Ahmed et al., 2012). It is seen as beneficial for patients at the beginning stages of treatment as well as the individuals that are continuing to maintain a stable state (Ahmed et al., 2012). Group therapy can be defined generally as a group of patients with schizophrenia that receive treatment in a group setting. It is a group “where individuals can talk about what it means to be diagnosed with schizophrenia, where they could learn about their illness, where they could question their treatment and where they could openly discuss their recent terrifying symptoms” (Miller, 2002). Studies have shown beneficial and effective peer treatment for individuals with schizophrenia.

Effectiveness. This study compares two groups, one that receives group intervention and the other that receives traditional/ routine care (McCay et al., 2006). This study “employed a pre-test, post- test quasi-experimental design with a non-equivalent comparison group” (McCay et al., 2006). The participants were 52 young adults that had just had their first episode and were DSM-IV diagnosed with schizophrenia (McCay et al., 2006). They were assigned to one of two groups; the experimental group was a 12-week group intervention program and then the control group receiving the traditional care (McCay et al., 2006). Pretest and posttest measures were collected using questionnaires: The Modified Engulfment Scale, Quality of Life Scale and The Positive and Negative Symptom Scale (McCay et al., 2006). The treatment group showed a significant improvement in posttest scores on the questionnaires in comparison to their pretest scores (McCay et al., 2006). The control group showed no significant changes in their scores from pretest to posttest (McCay et al., 2006). Based on research, it appears beneficial for individuals with schizophrenia to have a peer that understands first hand the stigmas, lack of self-esteem and the engulfment that comes with the disorder (McCay et al., 2006; Miller, 2002; Ahmed et al., 2012).

Family Therapy. Marriage and family therapy has not been a very accepted treatment option over the years but is starting to show it’s importance, especially related to the treatment of schizophrenia (Hecker & Wetchler, 2003). “Marriage and family therapy is a model of mental health treatment that takes a family perspective toward emotional problems and psychopathology” (Hecker & Wetchler, 2003, p. 3). Related more specifically to schizophrenia, “positive family involvement in the treatment process could enhance the potential of a better outcome for the patient and ultimately of the family” (Hecker & Wetchler, 2003, p. 476). This notion is from the theory of expressed emotion (EE), suggesting that individuals with schizophrenia are vulnerable and highly responsive to stress involving the expression of intense, negative emotions (Hecker & Wetchler, 2003, p. 476). EE is measured in most of the studies regarding the caregiver/family members EE level and how it affects individuals with schizophrenia. Family Intervention therapy compared to routine case management, “has shown a reduction in patients’ relapse rate, hospital admissions, improve patients’ compliance to antipsychotic drug treatments, and improve social impairment as well as the levels of EE within the family”(Tomás et al., 2012).

Effectiveness. Several studies mentioned by Hecker and Wetchler (2003) were completed to compare groups of patients with a strong family involvement in addition to routine care compared to a group of patients receiving just routine care (p. 476). Both of these groups involved patients cooperating with regular medication management (Hecker & Wetchler, 2003, p. 476). The success of the treatments were measured through the rate of relapse in patients over six months to two years (Hecker & Wetchler, 2003, p. 476). The studies confirmed “ that programs containing some form of family intervention, combined with routine care, are more effective than routine care alone” (Hecker & Wetchler, 2003, p. 476). The studies more specifically showed that “over a two-year period family interventions are more effective in delaying relapses and improving social function than are the individual supportive or skill-oriented interventions” (Hecker & Wetchler, 2003, p. 476).

Another study looks at family intervention therapy also called “family work”. This study is more recent that Hecker and Wetchler’s mentioned studies. This study used a longitudinal, experimental, prospective and retrospective design (Tomás et al., 2012). Participants included a group of 23 schizophrenia patients from five different multicentre hospital intervention settings and their 35 key relatives (Tomás et al., 2012). Patients were “18–65 years of age, with schizophrenia DSM-IV-TR diagnosis for at least five years, following outpatient care, and living with one or more key relatives with high EE” (Tomás et al., 2012). The intervention was based on the “family work” model which included 11- one hour sessions for each family at their home; this averaged two sessions a month at first and tampered to one session a month over the nine month study (Tomás et al., 2012). The assessment of the patient and family occurred at baseline, after the intervention and at the six-month follow-up (Tomás et al., 2012). Several tools were used to measure effectiveness of the study, including measurement of EE, Brief Psychiatric Rating Scale, Quality of Life and family interview tools (Tomás et al., 2012). The study even assessed the impact of the intervention on the family members. The study found “a global improvement in both patients’ clinical and social functioning characteristics and some improvement in key relatives’ EE, burden of care and quality of life dimensions. The majority of these improvements were maintained at the six-month follow-up” (Tomás et al., 2012).

Discussion

The treatment of schizophrenia under the recovery movement using psychosocial and psychological effective treatments did not begin until the 1990s (Peebles et al., 2007; Ahmed et al., 2012). It appears that the recovery model has broken ground for treatments that focus on the overall individual and how they will maintain an independent stable life instead of taking numerous medications while being hospitalized repeatedly. From this literature review it is evident that there are several psychosocial and psychological treatments that can be provided to individuals in addition to their routine care. Routine care is considered overall medical health and pharmaceutical management. Research supporting these treatments continues to be published while creating ideas for new studies to continue to enhance psychosocial and psychological treatments with minimal medical intervention. Schizophrenia appears to be a disorder where several factors need to be taken into consideration for the individual to receive the best treatment option for that individual. Treatment compliance is the heart of an individual’s treatment success. Numerous studies and research review articles I found looked at treatment compliance related to the reduction of symptoms (Tarrier et al., 2000; Jones et al., 2012; Tsang et al., 2010; Priebe et al., 2013; Larsson, Loewenthal, & Brooks, 2012; Ahmed et al., 2012; Miller, 2002; McCay et al., 2006; Tomás et al., 2011; El-Missiry et al., 2011) There are several factors such as self-stigma, self-esteem, cognitive functioning, acceptance of medications, acceptance of diagnosis, and even family support that has been shown through this literature review to effect the effectiveness of an individual’s success with treatment. (Tarrier et al., 2000; Jones et al., 2012; Tsang et al., 2010; Priebe et al., 2013; Larsson, Loewenthal, & Brooks, 2012; Ahmed et al., 2012; Miller, 2002; McCay et al., 2006; Tomás et al., 2011; El-Missiry et al., 2011) “Treatment non-adherence limits the dissemination of clinical services to enhance independent living, employment, and quality of life among individuals with schizophrenia” (Tsang et al., 2010).

Over the years, there have been several improvements in anti-psychotic medication and psychological treatments represented by the literature found. Still, “schizophrenia patients continue to experience persistent symptoms and full remissions are infrequent. Patients often do not adhere to existing pharmacological and psychological treatments and even when they do, currently available treatments have only a limited effect”(Priebe, et al., 2013). This statement is mentioned in several articles in different ways related to their specific research but it brings up several more research questions to explore related to the treatment of schizophrenia. Through the research I did for this literature review and reviewing the articles, I thought of several questions that could not be addressed in further research. If these treatment options are being researched, why are they not more widely available to individuals with schizophrenia? The recovery model has brought a new way of looking at treatment for individuals with schizophrenia so why have the treatment options not changed? If the majority of treatment for patients with schizophrenia were psychosocial and psychological treatments, wouldn’t there be a reduction in the cost of care such as hospitalizations and the recovery treatment from a relapse? Further research needs to continue on psychosocial and psychological treatments with minimal medical intervention to reach the full acceptance of the mental health field.

References

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