Therapeutic management
Therapeutic management
The aims of treatment are to:
- Reduce distress associated with psychosis symptoms
- Promote social and educational recovery
- Reduce depression and social anxiety
- Prevent relapse
- Reduce vulnerability and promote resilience
- Prevent poor physical health.
The interventions recommended by NICE1 and BAP2 include peer-provided and self-management, psychological, psychosocial and pharmacological interventions. Psychological factors play an important role in schizophrenia and psychological interventions (cognitive behavioural therapy [CBT] and family interventions) should be made in conjunction with antipsychotic medication as this is the most effective way of managing a first psychotic episode and subsequent acute episodes.
Cognitive behavioural therapy assists in promoting recovery in patients with persisting symptoms and for those in remission.
Family intervention should be offered to all those who live with or are in close contact with the patient, particularly if the person has recently relapsed, is at risk of relapse or has persisting symptoms.
Arts therapies should be offered to people with psychosis or schizophrenia, particularly for the alleviation of negative symptoms.
Antipsychotics are used for the treatment of acute episodes and relapse prevention. They remain the primary treatment for psychosis and schizophrenia, and are available as oral, intramuscular (IM), or medium or long-acting IM preparations/depots.
The potency of the first-generation antipsychotics (FGA) was thought to depend entirely on dopamine-2 (D2) receptor blockade in the mesolimbic and cortical areas of the brain. Nigrostriatal D2 blockade causes extra-pyramidal symptoms (EPS) and the tuberoinfundibular D2 blockade is responsible for causing hyperprolactinaemia.
The second-generation antipsychotics (SGA) do not have such a high affinity for D2 receptors but have affinity for other receptor types, particularly serotonin receptors (5-HT2A).
An antipsychotic’s affinity at histamine, muscarinic and alpha-adrenergic receptors gives rise to other side-effects such as sedation, weight gain, blurred vision, dry mouth, constipation and postural hypotension. Antipsychotics have different potency and affinity at receptors, hence their very different side-effect profiles.
Irrespective of the different pharmacodynamics involved, there is no convincing evidence that any antipsychotic, except clozapine, is more effective than any other.3,4
Initially, SGAs were recommended over FGAs as they have fewer extrapyramidal symptoms. However, this recommendation has changed over time due to the risk of metabolic syndrome. The choice of antipsychotic medication should be made by the patient, the carer (if appropriate) and healthcare professional together. The decision should be based on likely benefits and possible side-effects of each drug, including:
- Metabolic (including weight gain and diabetes)
- EPS (including akathisia, dyskinesia and dystonia)
- Cardiovascular (including prolonging the QT interval)
- Hormonal (e.g. increasing plasma prolactin)
- Anticholinergic (constipation, urinary retention and reduced cognition)
- Other (e.g. unpleasant subjective experiences).
Reflective Exercise
How could you work in collaboration with local mental health services to increase access and help reduce health inequalitiess for patients with schizophrenia?