Treatments for Schizophrenia (Edexcel A-Level Psychology): Revision Notes
Treatments for Schizophrenia
Biological treatment: drug therapy
Types of antipsychotic medication
Antipsychotic medication represents the primary treatment approach for individuals diagnosed with schizophrenia. These drugs work to reduce symptoms linked to psychotic episodes, particularly delusional thoughts and hallucinations. Such symptoms can severely impact quality of life and make it difficult for patients to access other forms of support, so medication is typically offered as a first-line intervention.
Typical antipsychotics were the first generation of these medications, developed during the 1950s. Examples include:
- Chlorpromazine
- Haloperidol
- Fluphenazine
These drugs were effective but came with numerous unpleasant side effects, which prompted the development of second-generation alternatives.
The transition from typical to atypical antipsychotics marked a significant advancement in schizophrenia treatment. While typical antipsychotics were revolutionary when introduced in the 1950s, their side effect profile led to the development of newer medications with improved tolerability.
Atypical antipsychotics emerged in the 1990s and appear to produce fewer problematic side effects whilst maintaining effectiveness. Examples include:
- Clozapine
- Risperidone
- Olanzapine
The reduction in adverse effects has made atypical antipsychotics the preferred option for many patients. Clozapine, in particular, has demonstrated high effectiveness in managing positive symptoms of schizophrenia, including hallucinations and related psychotic experiences, as well as some negative symptoms such as emotional withdrawal (Brar et al., 1997). This effectiveness extends even to individuals who have not responded well to other medications.
Mechanism of action
Antipsychotic drugs operate by reducing dopamine levels in brain regions associated with psychotic symptoms. Their primary mode of action involves blocking dopamine receptors in these areas, which prevents dopamine from binding to receptors in the synapse. This process depolarises the neurons and produces a calming effect.
All antipsychotic medications appear to share this basic mechanism, specifically acting by blocking D2 receptors (dopamine receptors) in relevant brain regions. However, atypical antipsychotics differ somewhat in their action.
Differences in receptor binding
Evidence suggests that newer atypical drugs do not bind to receptors as strongly and may also block 5-HT2A receptors (serotonin receptors). These differences in action are thought to account for the reduced side effects associated with atypical drugs compared to typical antipsychotics (Seeman, 2002).
These medications can be administered as tablets or, in some circumstances, given by injection through a nurse. This flexibility is particularly important when there is concern about patient compliance with the treatment regimen.
Evaluation of drug therapy
Side effects and safety concerns
Major Treatment Limitation: Side Effects
A major limitation of using drug therapy for schizophrenia concerns the potentially serious side effects experienced by some patients.
Side effects can include:
- Drowsiness
- Blurred vision
- Rapid heart rate
Atypical antipsychotics have been associated with:
- Weight gain
- Metabolic changes
- Increased risk of diabetes
- Elevated cholesterol levels
Typical antipsychotics carry additional risks of:
- Movement and posture disturbances
- Tremors
- Muscle spasms
Long-term use of typical antipsychotics can result in tardive dyskinesia, a condition characterised by involuntary muscle spasms commonly occurring around the mouth, which can affect speech. This condition may be irreversible.
Clozapine and Agranulocytosis Risk
Clozapine, whilst being one of the most effective antipsychotics, carries a specific risk of developing agranulocytosis, which reduces the white blood cell count and increases infection risk. Consequently, patients taking clozapine must have blood tests every two weeks to monitor their blood count.
Treatment compliance
Research has demonstrated that many patients discontinue their medication due to severe side effects, which has serious implications for treatment effectiveness (Lieberman et al., 2005). Clozapine's generally lower incidence of side effects compared to similar drugs may explain its effectiveness, as patients are more likely to maintain compliance when experiencing fewer adverse effects.
Research Example: Comparing Atypical Antipsychotics
A study by McEvoy et al. (2006) compared the time taken to discontinue treatment across four atypical drugs. Patients in this study had already stopped taking another atypical drug because it was ineffective.
Key Findings:
- Clozapine was the most effective option for this patient group
- Participants continued clozapine considerably longer than the alternatives
- Symptom assessment after three months showed the greatest improvement in the group taking clozapine
This demonstrates clozapine's superior effectiveness, particularly for treatment-resistant patients.
Issues of social control
Considerable debate exists regarding whether certain medications have been used to make patients with unusual behaviour more manageable. Many older typical antipsychotic drugs made patients very passive, potentially making them easier for staff in institutions to control. This may have contributed to the drugs being subject to abuse in busy wards.
The "Pharmacological Straitjacket" Debate
Drug treatments that produce passivity effects have been regarded as pharmacological straitjackets. Opposition to using drugs for treating mental illness stems from concerns that pharmaceutical companies may be more interested in profit from their products than genuinely helping patients. Greater effort should be directed towards helping patients manage long-term effects and avoiding side effects associated with antipsychotic drug use.
Electroconvulsive therapy (ECT)
In the late 1930s, Ugo Cerletti used electroshocks to induce seizures in animals, later adapting this technique to treat people with schizophrenia. Electroconvulsive therapy (ECT) involves placing electrodes (paddles) on one (unilateral) or both (bilateral) sides of the head. A determined current of electricity is passed through the brain to induce a grand mal seizure. This procedure typically occurs approximately twice weekly over up to 12 sessions. The induction of seizures caused injury to patients, leading to the use of body restraints, mouth guards, muscle relaxant and anaesthesia.
Historical Controversy and Cultural Impact
During the 1960s, ECT faced criticism from the antipsychiatry movement for being a barbaric treatment for patients with behaviours that staff found difficult to manage. It was perceived as a form of social control to keep troublesome patients docile and easy to handle. The portrayal of ECT being used as social control appeared in the film "One Flew Over the Cuckoo's Nest".
Objections to ECT use largely saw it fall out of favour for schizophrenia treatment, and it is now typically used to stabilise mood disorders. However, recent guidelines for ECT use in schizophrenia have suggested it could be an effective treatment for immediate relief of catatonic symptoms resistant to drug treatments. Numerous studies and meta-analyses have been conducted to examine ECT effectiveness for schizophrenia, with some arguing it could be effective in conjunction with antipsychotic medication. However, conclusions have been mixed and some argue that research lacks the blind assessment necessary to establish effectiveness.
Psychological treatment: family therapy
Purpose and aims
The purpose of family therapy, or family intervention, is to support the whole family unit of an individual diagnosed with a mental illness. Living with someone who has experienced or is experiencing psychosis can be very challenging. Family therapy aims to develop a support network within the family whilst building a collaborative relationship between the family and the professionals providing treatment for the patient.
NICE Guidelines Recommendation
The NICE (National Institute for Health and Care Excellence) guidelines for treating schizophrenia state that family therapy should be offered to patients during their course of treatment. Substantial evidence demonstrates it can help reduce relapse rates and increase treatment compliance in patient groups.
An important feature of family therapy in schizophrenia involves encouraging the family to discuss openly the symptoms being experienced by the patient. Here the patient will be encouraged to explain what they experience as an 'expert' on schizophrenia. The family will also receive education on the causes of the illness to break down any concerns about 'blame' for the development of the psychosis. The whole family must understand the illness to gain a better understanding of the behaviours shown, such as learning that symptoms cannot be controlled by the patient during an episode of psychosis.
Drug therapy is also likely to form part of the treatment given, and the family will be offered information on how the medication works and what side effects to expect. As well as focusing on understanding the illness, family members are encouraged to discuss other day-to-day concerns they have. For instance, it may be frustrating to live with someone who no longer takes care of their personal hygiene, which could lead to family members getting angry with the patient. By discussing different viewpoints and considering how the family can work together to solve problems they all face, everyone is given a chance to state their views.
Benefits and rationale
The motivation for including family members in the treatment process stems from recognition that the demands of living with someone with a serious mental health problem like schizophrenia can be very high. The challenging behaviour caused by symptoms can be emotionally draining, and people might feel embarrassed or ashamed about talking to others outside the family about the person with schizophrenia.
Family therapy provides them the opportunity to air their concerns in a supported environment and work together to find solutions, or at least develop understanding that will reduce negative emotions. This, in turn, helps make the patient feel more supported in the home, which is thought to substantially impact the chances of treatment being successful.
Evaluation of family therapy
Effectiveness
Understanding Family Therapy's Role
Family therapy is not a treatment for schizophrenia per se and will not cure the disorder. Rather, it is a therapy to help families cope with the disorder, create a more manageable family environment, offer support and encourage medication compliance.
Research by Goldstein and Miklowitz (1995) reviewed studies examining family therapy effectiveness and found that substantial evidence suggested family interventions combined with medication were considerably more effective in reducing relapse rates than medication alone. However, they also noted that the level of effectiveness in family interventions was determined by the type of intervention offered.
Comparative Research: Family Therapy vs. CBT
A meta-analysis by Pilling et al. (2002) compared family therapy effectiveness with CBT as a treatment for schizophrenia, finding some differences in the effects of each type of therapy.
Family therapy was particularly effective in:
- Reducing relapse rates for episodes of psychosis
- Improving compliance with prescribed medication
This demonstrates family therapy's unique strengths in supporting long-term treatment adherence.
Practical limitations
Research Methodology Concern: Treatment Bias
The largest problem with research into family therapy effectiveness is that many studies cannot randomly allocate participants to either a treatment group (receiving family therapy) or control group (receiving no treatment). Participation in treatment programmes is often decided by clinicians. This means that likely only those patients regarded as best suited to family therapy will be given the opportunity to be on the programme, which may account for their improvement. This is known as treatment bias and represents an issue with much clinical research into therapy effectiveness.
Family therapy relies heavily on the whole family being open and honest, as well as being willing to work with therapists in supporting the patient. Not all families, or even all family members, will be willing or able to commit to this, which could account for the drop-out rates associated with family therapy. On its own, family therapy is not an effective therapy as it is an intervention for support for the family and to ensure the patient takes their medication. However, in combination with medication (the preferred treatment for schizophrenia), evidence has shown very positive outcomes for patients.
Long-term Focus and NHS Availability
The aim of family therapy is to achieve long-term maintenance of mental health. It is not designed to relieve symptoms but to reduce expressed emotion and prevent relapse through medication compliance and support.
One of the biggest limitations of family therapy is that, despite evidence of its effectiveness, it is not widely available on the NHS. Patients who could benefit from the therapy may not have access to it. One key outcome of family therapy is reduced relapse rates, which could vastly improve the quality of life of many patients diagnosed with schizophrenia and could save the NHS money, as fewer relapses mean fewer patients will be admitted to hospital at considerable expense.
Wider issues and debates
Ethics of treatment without consent
Legal and Ethical Considerations
If a patient is detained under Section 3 of the Mental Health Act (1983), treatment can be given without their consent if deemed necessary. Drug therapy is one of only three treatments that can be given in this way, and some argue this breaches ethical guidelines.
However, for treatment to be given without consent, the patient's current state of mind must be considered—that is, if they are putting themselves or others in danger. In fact, in some cases, it could be argued that the patient's symptoms could mean they are unable to know what is best for them, and receiving treatment forcibly may be the most positive course of action.
Research methodology considerations
Evaluating Treatment Effectiveness
When evaluating any therapy or treatment, it is useful to consider effectiveness, ethics and limitations. Covering these three elements allows for an overall discussion of critical evaluation relating to each treatment. Evidence should be considered as much as possible to illustrate these three points, which helps explain concepts clearly in exams using examples. Evaluation should involve both strengths and weaknesses, reaching a balanced conclusion or judgement.
Remember!
Key Points to Remember:
-
Antipsychotic medication is the primary treatment for schizophrenia, with atypical antipsychotics (e.g. clozapine) generally preferred over typical antipsychotics due to fewer side effects.
-
Mechanism of action: Antipsychotics work by blocking D2 dopamine receptors in the brain, reducing dopamine activity and alleviating positive symptoms.
-
Side effects are a major concern, particularly tardive dyskinesia (typical antipsychotics) and agranulocytosis (clozapine), affecting treatment compliance.
-
Family therapy aims to support families and improve treatment compliance rather than directly treating schizophrenia, and is most effective when combined with medication.
-
Evaluation requires consideration of effectiveness, ethics, and practical limitations, with research evidence supporting combined approaches (medication plus family therapy) as most effective in reducing relapse rates.