Therapies for the treatment of schizophrenia
Drug therapies involve the chemical treatment of schizophrenia through tablets and intravenous means. Anti-psychotic drugs come in two types: (1) typical, such as chlorpromazine, which arrests dopamine production through blocking receptors in synapses that absorb dopamine, to reduce positive symptoms, like hallucinations and delusions, and (2) atypical, such as clozapine, which acts on serotonin as well as dopamine production systems, affecting negative symptoms, like reduced emotional expression. Cognitive behavioural therapy (CBT) treats schizophrenia by modifying thought patterns to alter behavioural and emotional states. CBT aims to change the maladaptive thinking and distorted perceptions that are seen as underpinning the condition in order to modify hallucinations and delusional beliefs. Antipsychotic drugs are usually given first to reduce psychotic thought processes, so that CBT will be more effective. Family therapy treats schizophrenia by altering communication systems within families. It aims to (i) improve positive and decrease negative communication, (ii) increase tolerance levels and decrease criticism levels between family members, and (iii) decrease feelings of guilt among family members for causing the disorder. Token economies are a method of behaviour modification that reinforces target behaviours by awarding tokens that can be exchanged for material goods. It is targeted especially at low motivation, poor attention and social withdrawal among schizophrenic patients.
Fig 12.4 Cognitive behavioural therapy is a common psychological treatment of schizophrenia, but how effective is it?
Bagnall et al. (2003) compared the clinical effectiveness, safety and cost effectiveness of typical and atypical drugs in the treatment of schizophrenia, as well as assessing their effectiveness against treatment-resistant schizophrenia and first-onset schizophrenia. Data were compiled from 171 randomly controlled and 52 non-randomly controlled trials of the effectiveness of drug treatments. Additional data were compiled from 31 economic evaluations of antipsychotic drug treatments for schizophrenia. The data were analysed by two independent researchers to establish inter-rater reliability. It was found that atypical drugs were generally more effective than typical drugs in symptom reduction. Clozapine and zotepine were more effective treatments of treatment-resistant schizophrenia. No differences were found between typical and atypical antipsychotics in treating first-onset schizophrenia. Both treatments had differing forms of side-effects. Atypical drugs were more expensive. It was concluded that atypical drugs are generally more effective, no single drug is superior and different drugs suit different patients.
• Tarrier (2005) reviewed 20 controlled trials of CBT using 739 patients, finding persistent evidence of reduced symptoms, especially positive ones, lower relapse rates and a speedier recovery rate of acutely ill patients. However, these were short-term benefits, with follow-ups needed to assess CBT’s long-term benefits.
• McFarlane et al. (2003) reviewed available evidence to find that family therapy results in reduced relapse rates, symptom reduction in patients and improved relationships among family members that leads to increased wellbeing for patients. This suggests that family therapy is an effective treatment, with an indication that better family relationships are the key element.
• Dickerson et al. (2005) reviewed 13 studies of token economy, finding it useful in increasing the adaptive behaviour of patients, which implies that it is an effective treatment. Token economy worked best in combination with psychosocial and drug therapies, though the specific benefits of the technique when used as a combination treatment were not identified, suggesting an area for future research.
Antipsychotics are effective, as they are relatively cheap to produce, easy to administer and have positive effects on many sufferers, allowing them to live relatively normal lives outside of mental institutions. Less than 3 per cent of people with schizophrenia in the UK live permanently in hospital.
Token economies generally lead to a safer and more therapeutic environment, with staff injuries reduced, therefore leading to lower staff absenteeism rates.
The Schizophrenia Commission (2012) estimates family therapy is cheaper than standard treatments for schizophrenia by £1,004 a patient over 3 years, which suggests it is more cost effective.
Evidence that atypical drugs are more effective than typical ones is generally of poor quality, based on short-term trials and difficult to generalise to all schizophrenic patients.
CBT is not suitable for all patients, especially those too disorientated, agitated or paranoid to form trusting alliances with clinicians.
Although family therapy is proven to be effective and is therefore desirable, due to cost restraints it is often not possible to offer it to all patients.
Token economies are frowned on by some clinicians, as they see them as humiliating and that their benefits do not generalise to real-life settings when tokens are withdrawn.
Research into treatments of schizophrenia allows psychologists to not only assess the effectiveness of individual therapies in relieving symptoms, but also assess their comparative cost effectiveness, potential side-effects, as well as determining which treatments best suit which types of patient.