Standard of Care For the Treatment of Schizophrenia

Dr. Haisook asked about treatment modes for patients with schizophrenia, and specifically, about the efficacy of psychotherapy for these patients.

I just finished an article about the standard of care for the treatment of individuals with schizophrenia. First, some definitions:

1) standard of care means the mode and level of care by any ethical health care provider that is accepted as responsible and appropriate
2) a diagnosis of exclusion is one which is not made without first ruling out all other possible diagnoses; schizophrenia is a diagnosis of exclusion, because of
the enormous consequence to the patient and his social supports
3) social recovery is a level of recovery in which the patient is able to function in society, e.g., maintain a residence and employment, maintain normal
psychosocial relationships
4) full recovery is a level of recovery in which the patient no longer has symptoms without the use of psychotropic medications
5) insightful psychotherapy is on the same end of the therapy spectrum as psychoanalysis; basically, in this type of therapy, the therapist and patient “dig
down” deep for insight into the current illness
6) supportive psychotherapy is at the opposite end of the therapy spectrum as insightful therapy; in supportive psychotherapy, only day-to-day functioning
is addressed; the patient is given encouragement and support, as well as counseling with the end of improved coping skills.

The anti-psychiatry groups have been a thorn in my side here on the internet. They insist that individuals with schizophrenia can achieve full recovery, and quote articles galore written by psychologists, social workers, and even psychiatrists, all of whom have some beef with psychiatry.

The article I read reflects what is taught in residency programs everywhere: that the more insightful the psychotherapy, the more likely it is that the patient with schizophrenia will relapse. The article was written by David W. Dunn, M.D., Program Director, Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Neurology, Indiana University.

The problem with insightful psychotherapy is that it causes the patient to dig down deep into the psyche to try to solve problems which are not based in reality. This causes a sudden collapse of the ego, because the patient cannot make sense of his perceptions in the background of reality.

For example, one of my patients believes he is being watched constantly. He hears noises around the house that he attributes to “spies.” Understandably, this causes a great deal of anxiety and depression. When confronted with the small likelihood that this is indeed happening, he “melts down.” No amount of psychotherapy will help him get at the root of his delusions (fixed, false belief). I know, because I tried. On the other hand, he thrives with judicious use of an antipsychotic and antidepressant, as well as regularly scheduled visits, in which the focus is supportive therapy.

I have seen many patients afflicted with schizophrenia who are referred to me by a psychiatric facility because they relapsed after undergoing insightful psychotherapy with a psychologist or other mental health care provider. Sometimes, they are even encouraged to stop taking their medications by therapists, believing they are unnecessary for the treatment of schizophrenia. There is only one consequence: relapse.

Perhaps psychologists are lulled into believing that their patient has achieved full recovery because they don’t return to the office. Quite the contrary, the patient is actually harmed by the therapy, relapses, is admitted to the hospital, often against his/her will and/or given medications against his/her will. Those patients are strongly cautioned against returning to insightful psychotherapy. Once they are stabilized, they are often able to understand the problem with that kind of therapy.

Another article, written by Paul S. Gerstein, M.D., a Senior Staff Physician, Department of Emergency Medicine, at Holyoke Medical Center. He states:

“…to prevent or ameliorate schizophrenia in vulnerable individuals, such as those with a family history of the disease who are showing possible early symptoms. Regimens include early administration of the newer atypical antipsychotics, even before definitive symptoms appear, in association with psychotherapy to reduce stress.”

It has been widely observed that people who develop schizophrenia began to have prodromal signs after a series of stressors, or after a stressor with a major impact on their lives. Sometimes, prodromal signs are already present, but a full-blown psychotic break follows such stressors. Dr. Gerstein also states that the “primary treatment for schizophrenia is antipsychotic medications, with counseling methods and behavioral therapies having supportive, secondary roles.”

The completed suicide rate for those with schizophrenia is 10%. Over and over again, the research has overwhelmingly shown that antipsychotic medication does help patients achieve social recovery. Antipsychotic medications have improved greatly within the last several years. They are not without side effects, and some individuals are more sensitive to side effects than are others. There are many ways to deal with the side effects of this kind of medication. Patients need not suffer from their medication, and they need not go untreated.

copyright © “Dr. W” 2006