Balancing the Mind in Schizophrenia

(May 2005) - Schizophrenia is a mysterious illness affecting over 2 million people in the United States. It causes withdrawal from reality, disordered thinking, hallucinations and confusion on the part of both the patient and their family and friends. Finding the right medication at the right dose is essential to help people with schizophrenia tame the chaos to maintain as normal a life as possible.

However, treating people with schizophrenia requires constant observation to achieve the right balance; there are the drugs to quiet the hallucinations, and many more to treat the side effects of the primary drugs. Dr. Joel Jeffries, staff psychiatrist at the Center for Addiction and Mental Health in Toronto, Canada, helps to make sense of the treatment options.

What is someone with schizophrenia experiencing?

Schizophrenia is a mental disorder, a disease of the brain. Nobody really knows what is wrong with the brain but it looks like it involves a problem with certain brain chemicals called neurotransmitters, in particular the release of excessive dopamine in certain parts of the brain.

Somebody who has schizophrenia is experiencing a disorganization of a variety of brain functions. In fact, some are very conspicuous; they are the distinctive symptoms of schizophrenia. The obvious one is making inappropriate connections or misinterpretations. A very common problem for someone with schizophrenia is hallucinations. You're actually getting messages from within the brain, but they appear to be coming from outside. Then associated with hallucinations are ideations, where you think that other people are communicating with you, telepathically giving you ideas, or thinking that your faults are known to other people.

Then the other thing that's very central to schizophrenia is that the actual thinking itself gets disorganized. It's what we call "thought disorder." For example, feelings get disconnected. In schizophrenia, these thoughts often begin without the usual kinds of triggers; so you get angry or depressed or anxious or bewildered without the sort of things that would normally set someone off. Sometimes these feelings occur spontaneously or as a reaction to the ideational changes or hallucinating experiences. So, your thinking and your feelings now become disorganized and often disconnected.

There are also often physical changes—disruptions in appetite and sleep patterns—so the disease seems to affect the brain very broadly.

What are the goals of treatment in schizophrenia?

The primary goal of treatment is to reduce what are called the "positive symptoms" of schizophrenia: hearing voices, the thought disorder and other problems in thinking, changes in mood. Medication should help with all those things.

Counseling, psychotherapy and social rehabilitation can help with more of what we call "negative symptoms." This often gets lost at first because you're so busy treating the positive symptoms, but people also lose motivation, the capacity to relate socially, and the capacity to organize themselves as they used to do before.

What types of medications are available for schizophrenia?

The most common modern medications currently prescribed are novel antipsychotics: risperidone (Risperdal®), olanzapine (Zyprexa®, Zydis®), quetiapine (Seroquel®), ziprasidone (Geodon®). And then there is aripiprazole (Abilify®), which acts differently on the brain than others. All these drugs block dopamine in those parts of the brain where excessive dopamine is contributing to psychosis. They primarily dampen positive symptoms, but they may also help with negative symptoms. But this is a little harder to prove and they certainly do not do so for all patients.

[The classic antipsychotic drugs, which include chlorpromazine and haloperidol have been largely replaced by the novel antipsychotics because of many unwanted side effects.]

What are the side effects of antipsychotics?

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Every drug has different side effects. Many of the novel antipsychotic drugs cause weight gain. Some have a propensity to cause diabetes. The classic antipsychotic drugs didn't have those problems as much, but the reason that they've been displaced by the newer drugs to a great extent is that they caused a lot of muscular side effects: loss of facial expression, tremor, stiffness and tardive dyskinesia, involuntary movements of the body, in particular the face if you stay on them a long time.

What other medications might people with schizophrenia need?

Having a major mental illness is upsetting, so anxiety is an intrinsic symptom of the illness. Although they're not treating the core of the illness, antianxiety medications are very useful for many people with schizophrenia. Not all of them need it, but for many of them they're useful. These drugs are also used to help with sleep. One of the common side effects of the antipsychotic drugs is a condition called akathisia, which is a type of bodily restlessness, like when you have too much caffeine in your body.

Depression is an intrinsic symptom of the psychosis; it has an affect on the person's self-image and self-confidence, they lose faith in their brain. It affects their schooling, work and relationships. They end up being put in hospitals, sometimes against their will. These things impact tremendously on the person's self-concept and, of course, that can feed the depression. To some extent depression responds to antipsychotics. But, they often need antidepressants as part of the collateral treatment. It's not the core of the treatment, but it's often a necessary additional treatment.

What is the best that can be achieved with medications?

The best depends on a number of factors. One is the intensity of the illness. Second, the sensitivity of the illness to treatment is important; that's very variable. And not only variable from person to person, but interestingly enough from time to time in the illness, so that early on, for the most part, the illness is very sensitive to treatment. After that, it becomes less and less sensitive and more difficult to treat. Then, after ten years, it starts to get easier to treat. You get more responsive. And the final factor is how skilled and lucky the treating physician is in getting the right treatment, the right dose and the patient to take it on regular basis because compliance [to the medication schedule] is a big issue.

It is possible for someone to get all the pieces together and lead a normal life, but it's uncommon. Some people actually have what appears to be a schizophrenic illness, recover and don't ever have another episode. It's rare. Maybe 10 to 15 percent of the total population with schizophrenia will recover very well with treatment and will stay well as long as they are on the treatment. The rest tend to have a more relapsing type of illness.

Are there any new medications or treatment options on the horizon?

There have been some long-acting drugs available for 40 years. These are injections that last anywhere from two to four weeks and, of course, they help deal with the issue of compliance, of not taking all medications. Those drugs, however, never caught on in the United States. In England, maybe as many as 25 percent of the patients would be on long-acting injections. In the United States it's only 5 percent. Then, when the new antipsychotics came along, even that 5 percent went down. But I think there is going to be a resurgence of interest in the long-acting injections now that a new long-acting risperidone injectable is available. There will probably be other new long-acting injectables coming along soon. So, I think that's going to be a bit of a switch in treatment. It's not really new drugs, just a new way of delivering them.

Do you think were getting better at treating schizophrenia?

Yes, but slowly and not dramatically.

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