A seminar on the management of schizophrenia from past to present. Discussion on Pharmacological as well as non-pharmacological therapies.

1. MANAGEMENT OF
SCHIZOPHRENIA
DR. SUBRATA NASKAR
Email : nsubrata09@gmail.com

2. PLAN OF PRESENTATION
1. INTRODUCTION
2. TREATMENT OF SCHIZOPHRENIA – THE PAST
3. TREATMENT OF SCHIZOPHRENIA – THE PRESENT
• PHARMACOLOGICAL TREATMENT
• PSYCHOSOCIAL TREATMENT
• REHABILITATION
4. UPCOMING STRATEGIES.
5. TREATMENT RESISTANT CASES.
6. INFORMATION REGARDING SOME NATIONAL & INTERNATIONAL ORGANIZATIONS
DEDICATED TO THE TREATMENT OF SCHIZOPHRENIA.
7. CONCLUSION
8. BIBLIOGRAPHY

3. INTRODUCTION
• SCHIZOPHRENIA IS A STRESS-RELATED, NEUROBIOLOGICAL DISORDER
CHARACTERIZED BY DISTURBANCES IN THE FORM AND CONTENT OF AN
INDIVIDUAL’S THOUGHT AND PERCEPTUAL PROCESS, AFFECT AND
SOCIAL AND INSTRUMENTAL ROLE BEHAVIOUR.
• THE PERVASIVE IMPACT OF SCHIZOPHRENIA ACROSS PERCEPTUAL,
COGNITIVE AND BEHAVIOURAL DOMAINS, AS WELL AS THE
HETEROGENEITY WITHIN THOSE DOMAINS REQUIRE A MULTIMODAL
AND COMPREHENSIVE APPROACH TO TREATMENT AND
REHABILITATION WHICH INVOLVES THE INDIVIDUAL AND HIS OR HER
ENVIORNMENT.

4. TREATMENT OF SCHIZOPHRENIA – PRE 1950
• FROM LITERATURES & DOCUMENTS THE TREATMENT OF SCHIZOPHRENIA
HAS GONE THROUGH A REVOULUTION.
LATE 19TH – EARLY 20TH
CENTURY
• SEDATING AGENTS SUCH AS BROMIDES AND BARBITURATES WERE
USED TO CONTROL AGITATION
• PHYSICAL TREATMENTS SUCH AS HYDROTHERAPY AND WET SHEET
PACKS WERE ALSO USED FOR THEIR CALMING EFFECTS.
EARLY 1920S
• SLEEP TREATMENT WITH BARBITURATES WAS INTRODUCED. THIS
TREATMENT WAS BASED ON THE OBSERVATION THAT PATIENTS
TENDED TO IMPROVE FOLLOWING AN OVERDOSE OF BARBITURATES.
• THE METHOD INVOLVED MAINTAINING PATIENTS IN A HIGHLY
SEDATED STATE FOR DAYS DURING WHICH THEY WOULD AWAKEN
ONLY FOR NECESSARY ACTIVITIES SUCH AS EATING AND PERSONAL
HYGIENE.

5. 1930s
• INSULIN COMA TREATMENT WAS INTRODUCED DURING THE 1930S.
• PATIENTS WERE ADMINISTERED GRADUALLY INCREASING DOSES OF INSULIN UNTIL A COMA WAS
INTRODUCED.
• AFTER AN HOUR OF MONITORING, GLUCOSE WAS ADMINISTERED, TERMINATING THE COMA.
• PATIENTS WERE COMMONLY ADMINISTERED AS MANY AS 20 COMAS. INSULIN COMA WAS WIDELY
USED IN THE TREATMENT OF PSYCHOSIS, SUGGESTING THAT IT MAY HAVE BEEN SOMEWHAT
EFFECTIVE.
1935
• PREFRONTAL LOBOTOMY WAS PROPOSED AS A TREATMENT FOR SERIOUS
MENTAL ILLNESSES BY MONIZ IN 1935.
• THE USE OF FRONTAL LOBOTOMY WAS COMMON PRIOR TO THE INTRODUCTION OF EFFECTIVE
ANTIPSYCHOTICS, ALTHOUGH THERE IS A REMARKABLE LACK OF CONTROLLED STUDIES COMPARING
PSYCHOSURGERY TO OTHER TREATMENTS.
• ALTHOUGH REPORTS SUGGEST THAT LOBOTOMY MAY HAVE BEEN EFFECTIVE IN REDUCING SEVERE
PSYCHOTIC SYMPTOMS, THEY ALSO RESULTED IN DETERIORATIONS IN OTHER AREAS.
• FOLLOWING LOBOTOMIES PATIENTS FREQUENTLY DEMONSTRATED PERSONALITY DETERIORATION
WITH IMPULSIVE AND PSYCHOPATHIC BEHAVIORS, AS WELL AS IMPAIRMENTS IN CONCEPT
FORMATION AND THE ABILITY TO PLAN.

6. • CONVULSIVE THERAPIES WERE DEVELOPED AFTER IT WAS OBSERVED THAT
SOME PATIENTS IMPROVED AFTER A SEIZURE.
• DRUGS SUCH AS CAMPHOR AND PENTYLENETETRAZOL (METRAZOL) WERE
USED INITIALLY TO INDUCE SEIZURES
• ABANDONED AFTER CERLETTI AND BINI PROPOSED THE USE OF ELECTRICALLY
INDUCED CONVULSIONS.
• IN ITS EARLY DAYS ELECTROCONVULSIVE THERAPY (ECT) WAS ADMINISTERED
WITHOUT ANESTHETICS OR MUSCLE RELAXANTS.
• THE LACK OF ANESTHETICS INSPIRED FEAR IN MANY PATIENTS, AND THE LACK
OF MUSCLE RELAXANTS LED TO INJURIES FROM FORCEFUL MUSCLE
CONTRACTIONS.

7. 1950 AND BEYOND – THE ERA OF ANTIPSYCHOTICS

8. EARLY 1950s
• RESERPINE, THE MOST POTENT OF THE RAUWOLFIA
ALKALOIDS, WAS INTRODUCED IN THE EARLY 1950S AND
WAS WIDELY PRESCRIBED IN THE UNITED STATES AND
ELSEWHERE FOR SCHIZOPHRENIA AND OTHER PSYCHOTIC
ILLNESSES.
EARLY
1950s
PROBABLY 1952
• THE DISCOVERY OF CHLORPROMAZINE IN THE EARLY 1950S
MAY BE THE MOST IMPORTANT SINGLE CONTRIBUTION TO
THE TREATMENT OF A PSYCHIATRIC ILLNESS.
• LABORIT, A SURGEON IN PARIS, NOTICED THAT
ADMINISTERING CHLORPROMAZINE TO PATIENTS PRIOR TO
SURGERY RESULTED IN AN UNUSUAL STATE IN WHICH THEY
SEEMED LESS ANXIOUS REGARDING THE PROCEDURE.
• IN 1952 HE CONVINCED DELAY AND DENIKER AND OTHER
PSYCHIATRISTS TO ADMINISTER CHLORPROMAZINE TO
PSYCHOTIC AND EXCITED PATIENTS, WITH ASTONISHING
RESULTS
HENRI LABORIT

9. 1958
• CLOZAPINE (CLOZARIL), THE FIRST EFFECTIVE
ANTIPSYCHOTIC WITH NEGLIGIBLE EXTRAPYRAMIDAL
SIDE EFFECTS (EPS), WAS DISCOVERED IN 1958 AND
FIRST STUDIED DURING THE 1960S.
• HOWEVER, IN 1976 IT WAS NOTED THAT CLOZAPINE WAS
ASSOCIATED WITH A SUBSTANTIAL RISK OF
AGRANULOCYTOSIS.
• THIS PROPERTY RESULTED IN DELAYS IN THE
INTRODUCTION OF CLOZAPINE.
1990
• IN 1990 CLOZAPINE FINALLY BECAME AVAILABLE IN THE
UNITED STATES, BUT ITS USE WAS RESTRICTED TO
PATIENTS WHO RESPONDED POORLY TO OTHER AGENTS.

10. •RISPERIDONE (RISPERDAL)1994
•OLANZAPINE (ZYPREXA)1996
•QUETIAPINE (SEROQUEL)1997
•ZIPRASIDONE (GEODON)2001
•ARIPIPRAZOLE (ABILIFY)2002
•PALIPERIDONE (INVEGA)2007

11. CURRENT THERAPEUTIC GOALS
•MINIMIZE SYMPTOMS
•MINIMIZE MEDICATION SIDE EFFECTS
•PREVENT RELAPSE
•MAXIMIZE FUNCTION
•RECOVERY

12. TYPES OF TREATMENT
• BIOLOGICAL TREATMENT
 PHARMACOTHERAPY
 ECT
 PSYCHOSURGERY (ANTERIOR CAPSULOTOMY)
 DEEP BRAIN STIMULATION
PSYCHOSOCIAL/ PSYCHOTHERAPEUTIC TREATMENT
 TYPES DESCRIBED LATER.

13. HOSPITALIZATION
• HOSPITALIZATION IS INDICATED FOR
• DIAGNOSTIC PURPOSES
• STABILIZATION OF MEDICATIONS
• PATIENTS' SAFETY BECAUSE OF SUICIDAL OR HOMICIDAL IDEATION
• GROSSLY DISORGANIZED OR INAPPROPRIATE BEHAVIOR, INCLUDING THE
INABILITY TO TAKE CARE OF BASIC NEEDS SUCH AS FOOD, CLOTHING, AND
SHELTER.
• ESTABLISHING AN EFFECTIVE ASSOCIATION BETWEEN PATIENTS AND
COMMUNITY SUPPORT SYSTEMS IS ALSO A PRIMARY GOAL OF HOSPITALIZATION.

14. HOSPITALIZATION
• SHORT STAYS OF 4 TO 6 WEEKS ARE JUST AS EFFECTIVE AS LONG-TERM
HOSPITALIZATIONS
• HOSPITAL SETTINGS WITH ACTIVE BEHAVIORAL APPROACHES PRODUCE
BETTER RESULTS THAN DO CUSTODIAL INSTITUTIONS.
• HOSPITAL TREATMENT PLANS SHOULD BE ORIENTED TOWARD PRACTICAL
ISSUES OF SELF-CARE, QUALITY OF LIFE, EMPLOYMENT, AND SOCIAL
RELATIONSHIPS.
• DURING HOSPITALIZATION, PATIENTS SHOULD BE COORDINATED WITH
AFTERCARE FACILITIES, INCLUDING THEIR FAMILY HOMES, FOSTER FAMILIES,
BOARD-AND-CARE HOMES, AND HALFWAY HOUSES.
• DAY CARE CENTERS AND HOME VISITS BY THERAPISTS OR NURSES CAN HELP
PATIENTS REMAIN OUT OF THE HOSPITAL FOR LONG PERIODS AND CAN
IMPROVE THE QUALITY OF THEIR DAILY LIVES.

15. PHARMACOTHERAPY
• ANTIPSYCHOTIC MEDICATIONS
• 1ST GENERATION
• 2ND GENERATION
• ADJUNCTIVE TREATMENT
• LITHIUM CARBONATE
• ANTIDEPRESSANT
• BENZODIAZEPINES
• ANTICONVULSANTS
• OTHER MEDICATIONS USED
• ANTI-PARKINSONIAN MEDICATIONS
• BETA BLOCKERS
• GLUTAMATE AGONISTS OR ANTAGONISTS
• AMPAkines
• mGluR PRESYNAPTIC ANTAGONISTS/POSTSYNAPTIC AGONISTS
• GLYT1 INHIBITORS
ORAL/PARENTERAL/DEPOT PREPARATION

16. STEPS ONE SHOULD FOLLOW BEFORE STARTING
AN ANTIPSYCHOTICS

17. • PRIOR TO STARTING AN ANTIPSYCHOTIC, CLINICIANS SHOULD
• DESCRIBE TO PATIENTS THE MEDICATION THAT IS BEING PRESCRIBED
• ITS TARGET SYMPTOMS, AND ITS POSSIBLE SIDE EFFECTS, PARTICULARLY THOSE THAT
ARE COMMON AND UNPLEASANT WHEN A DRUG IS FIRST STARTED (E.G., SEDATION
AND AKATHISIA)
• SINCE PATIENTS WITH SCHIZOPHRENIA MAY BE SUSPICIOUS, IT IS
PARTICULARLY IMPORTANT TO EMPHASIZE THAT PATIENTS CAN PARTICIPATE
AS COLLABORATORS IN INTERPRETING MEDICATION EFFECTS.
• SINCE PSYCHOTIC INDIVIDUALS MAY BE DEPENDENT ON THE HELP AND
SUPPORT OF THEIR FAMILIES, IT IS FREQUENTLY HELPFUL TO INVOLVE ONE OR
MORE FAMILY MEMBERS IN DECISION MAKING ABOUT DRUG TREATMENT.

18. • IN SOME SETTINGS AND LOCATIONS IT IS NECESSARY FOR PATIENTS TO GIVE
WRITTEN OR VERBAL CONSENT PRIOR TO RECEIVING AN ANTIPSYCHOTIC
MEDICATION.
• AS THE PATIENT IMPROVES, CLINICIANS MAY THEN ELABORATE ON THE COSTS
AND BENEFITS OF MEDICATION.
• FOR EXAMPLE, DETAILED DISCUSSIONS ABOUT TARDIVE DYSKINESIA OR WEIGHT SIDE EFFECTS ASSOCIATED WITH CHRONIC
TREATMENT MAY BE DEFERRED UNTIL THE PATIENT HAS IMPROVED AND LONG-TERM MAINTENANCE IS BEING CONSIDERED.
• CLINICIANS SHOULD BECOME FAMILIAR WITH LOCAL AND STATE LAWS THAT
AFFECT A PATIENT'S RIGHT TO REFUSE OR ACCEPT DRUG TREATMENT.
• UNDER SOME CONDITIONS, FAMILY MEMBERS WHO HAVE BEEN EDUCATED
ABOUT SCHIZOPHRENIA MAY BE HELPFUL IN CONVINCING PATIENTS TO ACCEPT
MEDICATION

19. CHOOSING THE RIGHT ANTIPSYCHOTIC
• ANTIPSYCHOTICS ARE MAINLY OF 2 TYPES:
• THE FIRST GENERATION ANTIPSYCHOTICS
• THE SECOND GENERATION ANTIPSYCHOTICS
• THE FGAS ARE FURTHER CATEGORIZED ACCORDING TO POTENCY
• LOW
• MID
• HIGH
• THE HIGHER POTENCY DRUGS HAVING MORE SPECIFICITY AND GREATER
AFFINITY FOR D2 RECEPTORS AND A GREATER TENDENCY TO CAUSE EPS.
• LOWER POTENCY DRUGS ARE LESS LIKELY TO CAUSE EPS, BUT TEND TO HAVE
MORE EFFECTS ON OTHER NEUROTRANSMITTER RECEPTORS AND ARE THUS
MORE LIKELY TO CAUSE POSTURAL HYPOTENSION, SEDATION, AND
ANTICHOLINERGIC EFFECTS.
CHLORPROMAZINE, THIORIDAZINE, MESORIDAZINE, CLOZAPINE, OLANZAPINE, QUETIAPINE
TRIFLUOPERAZINE, CHLORPROTHIXENE, LOXAPINE, MOLINDONE, ZIPRASIDONE
TRIFLUOPERAZINE, CHLORPROTHIXENE, LOXAPINE, MOLINDONE, ZIPRASIDONE

20. CHOOSING THE RIGHT ANTIPSYCHOTIC
• BEFORE CHOOSING A DRUG ONE SHOULD PROVIDE INFORMATION
AND DISCUSS THE LIKELY BENEFITS AND POSSIBLE SIDE EFFECTS OF
EACH DRUG, INCLUDING:
• METABOLIC (INCLUDING WEIGHT GAIN AND DIABETES)
• EXTRAPYRAMIDAL (INCLUDING AKATHISIA, DYSKINESIA AND DYSTONIA)
• CARDIOVASCULAR (INCLUDING PROLONGING THE QT INTERVAL)
• HORMONAL (INCLUDING INCREASING PLASMA PROLACTIN)
• OTHER (INCLUDING UNPLEASANT SUBJECTIVE EXPERIENCES).
©NICE clinical guideline

21. BEFORE STARTING ANTIPSYCHOTIC MEDICATION,
ONE SHOULD UNDERTAKE AND RECORD THE
FOLLOWING BASELINE INVESTIGATIONS
• WEIGHT (PLOTTED ON A CHART)
• WAIST CIRCUMFERENCE
• PULSE AND BLOOD PRESSURE
• BLOOD GLUCOSE, GLYCOSYLATED HAEMOGLOBIN (HBA1C)
• BLOOD LIPID PROFILE
• PROLACTIN LEVELS
• ASSESSMENT OF ANY MOVEMENT DISORDERS
• ELECTROCARDIOGRAM
• ASSESSMENT OF NUTRITIONAL STATUS, DIET AND LEVEL OF PHYSICAL
ACTIVITY. [NEW 2014]
©NICE clinical guideline

22. • AT THE START OF TREATMENT ONE SHOULD GIVE A DOSE AT THE LOWER
END OF THE LICENSED RANGE AND SLOWLY TITRATE UPWARDS WITHIN THE
DOSE RANGE
• ONE SHOULD CARRY OUT A TRIAL OF THE MEDICATION AT OPTIMUM
DOSAGE FOR 4–6 WEEKS. [2009; AMENDED 2014]
©NICE clinical guideline

23. • ONE SHOULD MONITOR AND RECORD THE FOLLOWING REGULARLY AND
SYSTEMATICALLY THROUGHOUT TREATMENT, BUT ESPECIALLY DURING
TITRATION:
• RESPONSE TO TREATMENT, INCLUDING CHANGES IN SYMPTOMS AND BEHAVIOUR
• SIDE EFFECTS OF TREATMENT, TAKING INTO ACCOUNT OVERLAP BETWEEN CERTAIN
SIDE EFFECTS
• AND CLINICAL FEATURES OF SCHIZOPHRENIA (FOR EXAMPLE, THE OVERLAP BETWEEN
AKATHISIA AND AGITATION OR ANXIETY) AND IMPACT ON FUNCTIONING
• THE EMERGENCE OF MOVEMENT DISORDERS
• WEIGHT, WEEKLY FOR THE FIRST 6 WEEKS, THEN AT 12 WEEKS, AT 1 YEAR AND THEN
ANNUALLY (PLOTTED ON A CHART)
• WAIST CIRCUMFERENCE ANNUALLY (PLOTTED ON A CHART)
• PULSE AND BLOOD PRESSURE AT 12 WEEKS, AT 1 YEAR AND THEN ANNUALLY
• FASTING BLOOD GLUCOSE, HBA1C AND BLOOD LIPID LEVELS AT 12 WEEKS, AT 1 YEAR
AND THEN ANNUALLY
• ADHERENCE
• OVERALL PHYSICAL HEALTH. [NEW 2014]
©NICE clinical guideline

24. COMPARISON OF ANTI-PSYCHOTICS
• THE CLINICAL ANTIPSYCHOTIC TRIALS OF INTERVENTION EFFECTIVENESS (CATIE)
SCHIZOPHRENIA TRIAL IN THE UNITED STATES AND THE COST UTILITY OF THE LATEST
ANTIPSYCHOTIC DRUGS IN SCHIZOPHRENIA STUDY (CUTLASS) IN THE UNITED KINGDOM,
FOUND THAT CLOZAPINE SEEMED ADVANTAGEOUS FOR INDIVIDUALS WITH REFRACTORY
SYMPTOMS BUT NO CLEARLY IMPORTANT ADVANTAGES IN EFFECTIVENESS FOR ANY OTHER
DRUG FOR MOST PATIENTS.
• BOTH STUDIES FOUND THAT PEOPLE TENDED TO CONTINUE TAKING OLANZAPINE LONGER
THAN OTHER ANTIPSYCHOTIC MEDICATIONS, BUT NEITHER STUDY FOUND GREATER
REDUCTIONS IN SYMPTOMS OR IMPROVEMENTS IN QUALITY OF LIFE FOR OLANZAPINE.
• NEITHER CATIE NOR CUTLASS FOUND SUBSTANTIAL ADVANTAGES IN OVERALL TOLERABILITY
OR ACCEPTABILITY FOR SGAS OVER FGAS.
• THE CATIE STUDY FOUND THAT SOME ANTIPSYCHOTICS, IN PARTICULAR CLOZAPINE,
OLANZAPINE, AND QUETIAPINE, WERE ASSOCIATED WITH WEIGHT GAIN AND SERUM LIPID
ABNORMALITIES THAT ARE RISK FACTORS FOR CARDIOVASCULAR DISEASE.

25. ATYPICAL ANTIPSYCHOTICS
• OLANZAPINE
+ LESS PROLACTIN ELEVATION
- WEIGHT GAIN, T2DM, ANTICHOLINERGIC SIDEEFFECTS
• QUETIAPINE
+ LESS EPS
- SOMNOLENCE, POSTURAL HYPOTENSION
• ARIPIPRAZOLE
+ LESS HYPERPROLACTINEMIA/WT GAIN/CARDIAC
DYSARRYTHMIA/GLUCOSE/LIPID PROFILE CHANGES
- INSOMNIA, AKATHISIA, ORTHOSTATIC HYPOTENSION,
CONSTIPATION
• AMISULPRIDE
+ EFFECTIVE IN BOTH POSITIVE & NEGATIVE SYMPTOMS,
LOW POTENCY FOR WT GAIN, GLUCOSE INTOLERANCE
- EPS, GALACTORRHOEA, AMENORRHEA, COSTLY
• CLOZAPINE
+ LESS EPS, TD
- AGRANULOCYTOSIS, ANTICHOLINERGIC SIDE
EFFECTS
• RISPERIDONE
+ CONSISTENT POSITIVE EFFICACY DATA, NO
ANTICHOLINERGIC SIDE EFFECTS.
- POSTURAL HYPOTENSION
• ZIPRASIDONE
+ EFFECTIVE IN BOTH POSITIVE & NEGATIVE
SYMPTOMS, ANXIOLYTIC & ANTIDEPRESSANT
PROPERTY, LOW POTENCY FOR WT GAIN,
COGNITIVE IMPAIRMENT
- EPS, ORTHOSTATIC HYPOTENSION, QT
PROLONGATION

26. IPS GUIDELINES RECOMMENDATION
• THERAPY INCLUDES 3 PHASES:
• ACUTE PHASE ( GOAL – SYMPTOM REDUCTION, HARM REDUCTION, IMPROVEMENT OF
FUNCTIONING)
• POST-ACUTE OR CONTINUATION PHASE (GOAL – CONSOLIDATION OF REMISSION,
RELAPSE PREVENTION)
• STABLE OR MAINTENANCE PHASE (GOAL- MAINTAINING OR IMPROVING
FUNCTIONING, PREVENTION OF RECURRENCE)
• CHOICE OF DRUGS DEPENDS UPON:
• SIDE EFFECT PROFILE
• PRIOR RESPONSE PATTERN
• PATIENT PREFERENCES & COST
• PREFERRED ROUTE OF ADMINISTRATION

27. • MINIMUM DURATION OF DRUG USE FOR ALL
DRUGS SHOULD BE 4-6 WEEKS, EXCEPT
CLOZAPINE (3-6 MONTHS)
• DOSES NEED TO BE INDIVIDUALIZES.
RECOMMENDED DOSE IS MOSTLY IN RANGE OF
300-1000 MG OF CHLORPROMAZINE
EQUIVALENTS PER DAY.
• TAPERING OF DOSE @ 20% OF THE INITIAL
DOSE IN EVERY 6 MONTHS, UNTIL A MINIMUM
EFFECTIVE DOSE IS REACHED.
Generic Name Equivalent dose
haloperidol 2 mg per day
chlorpromazine 100 mg per day
thioridazine 100 mg per day
thiothixene 4 mg per day
risperidone (oral) 2 mg per day
olanzapine 5 mg per day
fluphenazine (oral) 2 mg per day
trifluoperazine 2 mg per day
perphenazine 8 mg per day
molindone 10 mg per day
loxapine 10 mg per day
prochlorperazine 15 mg per day
quetiapine 75 mg per day
mesoridazine 50 mg per day
clozapine 50 mg per day
ziprasidone 60 mg per day
haloperidol (depot) 30 mg per 28 days
fluphenazine (depot) 2.5 mg per 21 days
aripiprazole 7.5 mg per day
risperidone (depot) 25 mg per 14 days

28. DURATION OF TREATMENT
• IT SHOULD BE INDIVIDUALIZED. THE SUGGESTED GUIDELINES ARE:
• 1ST EPISODE PATIENTS :1-2 YEARS OF MAINTAINANCE
• PATIENTS WITH SEVERAL EPISODE OR EXACERBATION : ≥5 YEARS OF MAINTAINANCE
• PATIENTS WITH H/O AGGRESSION, SUICIDE ATTEMPTS : INDEFINITE PERIOD EVEN LIFE
LONG

29. SIDE EFFECTS
• EXTRAPYRAMIDAL SIDE EFFECTS:
• DYSTONIA
• AKATHISIA
• PARKINSONISM
• TARDIVE DYSKINESIA

30. OTHER COMMON SIDE EFFECTS
• ANTICHOLINERGIC SIDE EFFECTS:
• DRY MOUTH
• CONSTIPATION
• BLURRY VISION
• TACHYCARDIA
• ORTHOSTATIC HYPOTENSION
• SEDATION
• WEIGHT GAIN
• NEUROLEPTIC DYSPHORIA
IT IS AN ALL-INCLUSIVE DESCRIPTIVE PHRASE
THAT ENCOMPASSES A VARIETY OF
UNPLEASANT SUBJECTIVE CHANGES IN
AROUSAL, MOOD, THINKING AND MOTIVATION
INDUCED BY NEUROLEPTIC DRUGS.

31. DYSTONIA
• SUSTAINED OR REPITITIVE INVOLUNTARY MUSCLE
CONTRACTIONS FREQUENTLY CAUSING TWISTING
MOVEMENTS WITH ABNORMAL POSTURES.
• TORTICOLLIS, OPISTHOTONUS, OCULOGYRIC
CRYSIS, TONGUE PROTRUSION
• DRAMATIC AND PAINFUL
• TREAT WITH I.M or I.V PROMETHAZINE OR
BENZTROPINE.

32. AKATHISIA
• RESTLESSNESS, PACING, FIDGETING, SUBJECTIVE JITTERINESS.
• RESEMBLES PSYCHOTIC AGITATION, AGITATED DEPRESSION.
• MANAGEMENT:
• LOWER THE ANTIPSYCHOTIC DOSE IF FEASIBLE.
• CHANGE TO DIFFERENT DRUG i.e TO AN ATYPICAL ANTIPSYCHOTIC
• ADJUNCTIVE MEDICINE:
• PROPRANOLOL OR ANOTHER BETA BLOCKER
• BENZTROPINE
• BENZODIAZEPINES.

33. PARKINSONIAN SIDE EFFECT
• RIGIDITY, TREMOR, BRADYKINESIA, MASK LIKE FACIES.
• MANAGEMENT:
• LOWER THE ANTIPSYCHOTIC DOSE IF FEASIBLE.
• CHANGE TO DIFFERENT DRUG i.e TO AN ATYPICAL ANTIPSYCHOTIC
• ADJUNCTIVE MEDICINE:
• BENZTROPINE
• TRIHEXYPHENIDYL
• PROMETHAZINE
• PRECYCLIDINE

34. TARDIVE DYSKINESIA
• INVOLUNTARY MOVEMENTS
• OFTEN CHOREOATHETOID.
• OFTEN BEGINS WITH TONGUE OR DIGITS, PROGRESSES TO FACE, LIMBS,
TRUNK.
• INCIDENCE IS ABOUT 3% PER YEAR WITH FGA.
• MAJOR RISK FACTORS:
• HIGH DOSES
• LONG DURATION
• INCREASED AGE.
• WOMEN
• H/O PARKINSONIAN S/E
• MOOD DISORDERS

35. TARDIVE DYSKINESIA
• PREVENTION:
• MINIMUM EFFECTIVE DOSE
• USE OF SGA
• MONITORING WITH AIMS SCALE
• TREATMENT
• LOWER DOSE USAGE
• SWITCHING TO ATYPICAL
• VITAMIN E
• TETRABENZINE
• CLOZAPINE IS SAID TO HAVE SOME BENEFICIAL ROLE IN IMPROVING TD

37. NEUROLEPTIC MALIGNANT SYNDROME
• SYMPTOMS:
• FEVER
• MUSCLE RIGIDITY
• AUTONOMIC INSTABILITY
• DELIRIUM
• MUSCLE BREAKDOWN INDICATED BY INCREASING CK.
• RARE BUT LIFE THREATENING.
• RISK FACTORS:
• USE OF HIGH DOSE AP
• USE OF HIGH POTENCY AP
• PARENTERAL ADMINISTRATION
• MANAGEMENT:
• STOP ANTIPSYCHOTIC
• SUPPORTIVE MEASURES – COOLING BLANKET, IV FLUID
• BROMOCRIPTINE
• DANTROLENE SODIUM

38. GLUTAMATE AGONISTS OR ANTAGONISTS FOR
TREATMENT OF PSYCHOSIS
NMDA ANTAGONISTS
• EXCESSIVE GLUTAMATE ACTIVITY COULD LEAD TO EXCITOTOXICITY AND
THUS INTERFERE WITH NORMAL NEURODEVELOPMENT
• EXCITOTOXICITY COULD ALSO CONTINUE DURING THE COURSE OF THE
ILLNESS AND BE LINKED TO DISEASE PROGRESSION IN SCHIZOPHRENIA
• HOWEVER, IT IS NOW ALSO WIDELY HYPOTHESIZED THAT ONCE THE
ILLNESS OF SCHIZOPHRENIA HAS DEVELOPED, NMDA GLUTAMATE
RECEPTORS ARE ACTUALLY HYPOFUNCTIONAL

39. • BLOCKING EXCESSIVE AND EXCITOTOXIC GLUTAMATE NEUROTRANSMISSION WITH
NMDA ANTAGONISTS MIGHT PREVENT DAMAGE OR DEATH TO NEURONS IN
SCHIZOPHRENIA
• THUS POTENT NMDA ANTAGONISTS MIGHT BLOCK EXCITOTOXICITY, BUT AT A PRICE
THAT THEY WOULD ALSO CAUSE OR WORSEN POSITIVE, COGNITIVE, AND NEGATIVE
SYMPTOMS OF SCHIZOPHRENIA
• LESS ROBUST NMDA ANTAGONISTS SUCH AS MEMANTINE OR EVEN AMANTADINE
THAT ONLY PARTIALLY BLOCK NMDA NEUROTRANSMISSION, MIGHT BE BETTER
OPTIONS
• ANOTHER POSSIBILITY IS TO BLOCK THE PRESYNAPTIC RELEASE OF GLUTAMATE,
WHICH IS THE HYPOTHESIZED MECHANISM OF CERTAIN ANTICONVULSANTS THAT
ALSO ACT AS MOOD STABILIZERS, LIKE LAMOTRIGINE AND RILUZOLE

40. AMPAKINES
• AMPA (Α-AMINO-3-HYDROXY-5-METHYL-4-ISOXAZOLE-PROPIONIC ACID) RECEPTORS ARE
ONE OF THE GLUTAMATE RECEPTOR SUBTYPES, AND THEY REGULATE ION FLOW AND
NEURONAL DEPOLARIZATION THAT CAN LEAD TO NMDA (N-METHYL-D-ASPARTATE)
RECEPTOR ACTIVATION.
• A NUMBER OF MODULATORS OF THE AMPA RECEPTOR ARE UNDER DEVELOPMENT,
INCLUDING THOSE THAT DO NOT ACT DIRECTLY AT THE GLUTAMATE SITE OF THE AMPA
RECEPTOR, BUT AT POSITIVE ALLOSTERIC MODULATING (I.E., PAM) SITES ON THIS
RECEPTOR
• PRELIMINARY EVIDENCE FROM ANIMAL STUDIES SUGGESTS THAT AMPAKINES MIGHT
ENHANCE COGNITION
• CX546
• CX619/ORG 24448
• ORG 25573
• ORG 25271
• ORG 24292
• ORG 25501
• LY293558
• THESE MIGHT HAVE MORE EFFICACY FOR COGNITIVE SYMPTOMS IN SCHIZOPHRENIA
WITHOUT SHOWING ACTIVATION OF POSITIVE SYMPTOMS OR NEUROTOXICITY.

41. mGluR PRESYNAPTIC ANTAGONISTS/POSTSYNAPTIC
AGONISTS
• ANOTHER CLASS OF GLUTAMATE RECEPTOR, KNOWN AS METABOTROPIC
GLUTAMATE RECEPTORS (mGluR), REGULATES NEUROTRANSMISSION AT
GLUTAMATE SYNAPSES
• THEY COULD POTENTIALLY PREVENT EXCESSIVE GLUTAMATE RELEASE FROM
GLUTAMATE NEURONS AND THEREBY IMPROVE THE SYMPTOMS OF
SCHIZOPHRENIA.
• ONE SUCH COMPOUND, LY2140023, HAS BEEN TESTED WITH PROOF OF
CONCEPT OF EFFICACY IN SCHIZOPHRENIA

42. GLYT1 INHIBITORS
• GLYCINE TRANSPORTERS ON GLIAL CELLS, KNOWN AS GLYT1, HAS ROLE IN
TERMINATING THE ACTION OF GLYCINE RELEASED BY GLIAL CELLS INTO THE
SYNAPSES TO ACT AT THE GLYCINE SITE OF NMDA RECEPTORS.
• GLYT1 INHIBITION COULD POTENTIALLY IMPROVE COGNITIVE AND NEGATIVE
SYMPTOMS OF SCHIZOPHRENIA BY ENHANCING THE AVAILABILITY OF
GLYCINE AT HYPOFUNCTIONING NMDA RECEPTORS.
• SEVERAL GLYT1 INHIBITORS ARE NOW IN CLINICAL TESTING, INCLUDING THE
NATURAL AGENT N-METHYLGLYCINE, ALSO KNOWN AS SARCOSINE

43. ELECTROCONVULSIVE THERAPY
• SCHIZOPHRENIA ITSELF IS NOT A PRIMARY INDICATION FOR ECT.
• THE INDICATIONS FOR ECT IN SCHIZOPHRENIA ARE:
• CATATONIC STUPOR
• UNCONTROLLED CATATONIC EXCITEMENT.
• ACUTE EXACERBATIONS NOT CONTROLLED WITH DRUGS
• SEVERE SIDE EFFECTS WITH DRUGS IN PRESENCE OF UNTREATED OR
RESISTANT SCHIZOPHRENIA
• RISK OF SUICIDE, HOMICIDE OR DANGER OF ANY KIND OF PHYSICAL ASSAULT.

44. PSYCHOSURGERY (ANTERIOR CAPSULOTOMY)
• ANTERIOR CAPSULOTOMY WAS DEVELOPED
IN SWEDEN, WHERE IT BECAME THE MOST
FREQUENTLY USED PROCEDURE.
• THE AIM OF THE OPERATION IS TO
DISCONNECT THE ORBITOFRONTAL CORTEX
AND THALAMIC NUCLEI
• NEUROSURGICAL TREATMENT IS OFFERED
TO A SMALL NUMBER OF PATIENTS
SEVERELY DISABLED BY OTHERWISE
INTRACTABLE MENTAL DISORDER.

45. DEEP BRAIN STIMULATION
• DEEP BRAIN STIMULATION (DBS) INVOLVES CREATING A SMALL HOLE IN
THE SKULL AND PASSING A FINE WIRE INTO SELECTED BRAIN REGIONS.
• THIS WIRE CAN BE EXCITED ON ITS TERMINAL END BY A PACEMAKER-
LIKE DEVICE CONNECTED SUBDERMALLY AND IMPLANTED IN THE CHEST
WALL.
• WHEN THE DBS IS IMPLANTED, THE WIRE STIMULATES AT HIGH
FREQUENCIES AND TEMPORARILY STOPS THE FUNCTION AT THAT
REGION.
• RECENT RESULTS OF DBS TREATMENT OF PSYCHIATRIC DISORDERS ARE
AUSPICIOUS.

46. MANAGEMENT OF SOME SPECIFIC
CONDITIONS

47. MANAGEMENT OF CATATONIA
LORAZEPAM UPTO 4MG/DAY.
START WITH 1MG & GIVE 1 MG
IF NO EFFECT AFTER 3 HOURS.
FROM NOW ON ONLY IM ROUTE
LORAZEPAM HIGH DOSE. 8-
24MG/DAY. ECT
IF NO RESPONSE
AFTER 1-2 DAYS
IF NO RESPONSE
AFTER 3-4 DAYS
THE MAUDSLEY PRESCRIBING GUIDELINES IN PSYCHIATRY 11TH EDITION

48. CONTROLLING VIOLENCE IN SCHIZOPHRENIA
• PERSONS WHO ARE PARANOID OR IN A STATE OF CATATONIC EXCITEMENT REQUIRE
TRANQUILIZATION.
• EPISODIC OUTBURSTS OF VIOLENCE RESPOND TO
• HALOPERIDOL (HALDOL)
• ALPHA 2-ADRENERGIC RECEPTOR ANTAGONISTS (BETA-BLOCKERS)
• CARBAMAZEPINE (TEGRETOL)
• LITHIUM.
• SOMETIMES, DRUGS SUCH AS HALOPERIDOL (5 TO 10 MG EVERY HALF-HOUR TO AN
HOUR) ARE NEEDED UNTIL A PATIENT IS STABILIZED.
• BENZODIAZEPINES MAY BE USED INSTEAD OF, OR IN ADDITION TO ANTIPSYCHOTICS
(TO REDUCE THE ANTIPSYCHOTIC DOSAGE).
• PERSONS WITH ALLERGIC OR ABERRANT RESPONSES TO ANTIPSYCHOTICS AND
BENZODIAZEPINES ARE TREATED WITH AMOBARBITAL (AMYTAL), 130 MG ORALLY OR
INTRAMUSCULARLY (IM), PARALDEHYDE, OR DIPHENHYDRAMINE (BENADRYL), 50 TO
100 MG ORALLY OR IM.

49. CONTROLLING VIOLENCE IN SCHIZOPHRENIA
• VIOLENT, STRUGGLING PATIENTS ARE SUBDUED MOST EFFECTIVELY WITH
AN APPROPRIATE SEDATIVE OR ANTIPSYCHOTIC.
• DIAZEPAM (VALIUM), 5 TO 10 MG, OR LORAZEPAM (ATIVAN), 2 TO 4 MG,
MAY BE GIVEN SLOWLY INTRAVENOUSLY (IV) OVER 2 MINUTES.
• CLINICIANS MUST GIVE IV MEDICATION WITH GREAT CARE TO AVOID
RESPIRATORY ARREST.
• PATIENTS WHO REQUIRE IM MEDICATION CAN BE SEDATED WITH
HALOPERIDOL, 5 TO 10 MG IM.
• DURING THE PRELIMINARY TREATMENT, A PATIENT'S BLOOD PRESSURE
AND OTHER VITAL SIGNS SHOULD BE MONITORED.

50. NON PHARMACOLOGICAL MANAGEMENT

51. IT INCLUDES
• PSYCHOEDUCATION
• INDIVIDUAL PSYCHOTHERAPY
• GROUP PSYCHOTHERAPY
• SUPPORTIVE PSYCHOTHERAPY
• SOCIAL SKILL TRAINING
• COGNITIVE BEHAVIOURAL THERAPY
• FAMILY ORIENTED THERAPY
• PERSONAL THERAPY
• DIALECTICAL BEHAVIOUR THERAPY
• VOCATIONAL THERAPY
• ART THERAPY

52. PSYCHOEDUCATION
• IT EMPOWERS THE PATIENT TO TAKE CONTROL OF THEIR OWN
ILLNESS
• START BASIC AND ACQUIRE CONSENT TO DISCUSS WITH PATIENT’S
FAMILY.
• BUT FOREMOST ONE HAS TO BE CONFIDENT WITH ONE’S DIAGNOSIS
AS ITS UNFAIR TO LABEL A PATIENT ‘SCHIZOPHRENIC’ IF THEY ARE
NOT. THEY MAY HAVE TO WEAR THE STIGMA FOR THE REST OF THEIR
LIVES !!!

53. PSYCHOEDUCATION
• PROVIDE INFORMATION ABOUT THE DISEASE LIKE COURSE,
SYMPTOMS, TREATMENTS AND PROGNOSIS.
• BE SUPPORTIVE.
• ONE IMPORTANT AIM IS TO DECREASE EXPRESSED EMOTIONS [
HOSTILITY, CRITICISM]
• NOT BLAMING

54. RELAPSE SIGNATURE AND PREVENTION
PLANS
• IT IS A SET OF INDIVIDUALISED SYMPTOMS OCCURING IN A SPECIFIC
ORDER OVER A PARTICULAR TIME THAT THE PATIENT CAN LEARN TO
IDENTIFY AND MANAGE THEMSELVES.
• IT HELPS TO IDENTIFY THE EARLIEST SIGNS OF IMPENDING PSYCHOTIC
RELAPSE [SUBTLE CHANGES IN THOUGHT, AFFECT AND BEHAVIOUR
PRECEDING DEVELOPMENT OF FRANK PSYCHOSIS]
• IT OFFERS TIMELY AND EFFECTIVE INTERVENTION TO ARREST THEIR
PROGRESSION TOWARDS FRANK PSYCHOSIS.

55. PSYCHOTHERAPY [INDIVIDUAL]
• STUDIES OF THE EFFECTS OF INDIVIDUAL PSYCHOTHERAPY IN THE TREATMENT
OF SCHIZOPHRENIA HAVE PROVIDED DATA THAT THE THERAPY IS HELPFUL AND
THAT THE EFFECTS ARE ADDITIVE TO THOSE OF PHARMACOLOGICAL
TREATMENT.
• IN PSYCHOTHERAPY WITH A SCHIZOPHRENIA PATIENT, DEVELOPING A
THERAPEUTIC RELATIONSHIP THAT THE PATIENT EXPERIENCES AS SAFE IS
CRITICAL.
• THE THERAPIST'S RELIABILITY, THE EMOTIONAL DISTANCE BETWEEN THE
THERAPIST AND THE PATIENT, AND THE GENUINENESS OF THE THERAPIST AS
INTERPRETED BY THE PATIENT ALL AFFECT THE THERAPEUTIC EXPERIENCE.
• PSYCHOTHERAPY FOR A SCHIZOPHRENIA PATIENT SHOULD BE THOUGHT OF IN
TERMS OF DECADES, RATHER THAN SESSIONS, MONTHS, OR EVEN YEARS.
• THE MAJOR AIM IS TO CONVEY THE IDEA THAT THE THERAPIST IS TRUSTWORTHY,
WANTS TO UNDERSTAND THE PATIENT AND TRIES TO DO SO, AND HAS FAITH IN
THE PATIENT'S POTENTIAL AS A HUMAN, NO MATTER HOW DISTURBED, HOSTILE,
OR BIZARRE THE PATIENT MAY BE AT THE MOMENT.

56. SUPPORTIVE PSYCHOTHERAPY
• FOCUSSED ON THE ‘HERE & NOW’ OF THE PATIENT’S LIFE.
• AIMS TO HELP THE PATIENT DEFINE REALITY MORE CLEARLY AND SOLVE
PRACTICAL PROBLEMS.
• INVOLVES:
• PROVIDING REASSURANCE
• OFFERING EXPLANATIONS & CLARIFICATION
• GIVING GUIDANCE & SUGGESTIONS.
• REGULAR AND SUPPORTIVE INTERACTION WITH A PSYCHOTHERAPIST MAY
REDUCE THE PATIENT’S FEELINGS OF ALONENESS AND DESPAIR.
• A POSITIVE RELATIONSHIP WITH THE PRESCRIBING PSYCHIATRIST MAY
ALSO ENHANCE THE PATIENT’S ADHERENCE TO PRESCRIBED MEDICATION.
• REDUCES SUICIDAL IDEAS AND BEHAVIOURS.

57. GROUP THERAPY
• GROUP THERAPY FOR PERSONS WITH SCHIZOPHRENIA GENERALLY
FOCUSES ON REAL-LIFE PLANS, PROBLEMS, AND RELATIONSHIPS.
• GROUPS MAY BE
• BEHAVIORALLY ORIENTED
• PSYCHODYNAMICALLY OR INSIGHT ORIENTED
• OR SUPPORTIVE.
• GROUP THERAPY IS EFFECTIVE IN
• REDUCING SOCIAL ISOLATION
• INCREASING THE SENSE OF COHESIVENESS
• IMPROVING REALITY TESTING FOR PATIENTS WITH SCHIZOPHRENIA

58. SOCIAL SKILL IMPROVEMENT

60. COGNITIVE BEHAVIOURAL STRATEGIES
• EMOTIONAL DISTRESS IS ASSUMED TO BE ASSOCIATED WITH FAULTY
THINKING, WHICH, IF MODIFIED CAN ALTER EMOTIONAL RESPONSES.
• GENERALLY STARTS WITH SEVERAL SESSIONS ASSESSING THE
PATIENT’S SPECIFIC SYMPTOMS AND THE DISTRESS ASSOCIATED WITH
THE SYMPTOMS.
• COPING STRATEGIES THAT THE PATIENT HAS USED MAY ALSO BE
REVIEWED.
• THE THERAPY AIMS TO ADDRESS ISSUES SYSTEMATICALLY OVER A
FIXED NUMBER OF SESSIONS.

61. CONCERNED TOPIC
SPECIFIC THERAPEUTIC STRATEGIES APPLICATION
DETERMINE THE FOCUS
OF THE SUBSEQUENT
SESSIONS
HOMEWORK EXERCISES, ACTIVITY SCHEDULE MAINTENANCE ADVISED
THE THERAPIST FOCUSES ON ANY COEXISTING ANXIETY AND DEPRESSION
THERAPIST TURNS TO SPECIFIC POSITIVE PSYCHOTIC SYMPTOMS THAT THE PATIENT EXPERIENCES
NEGATIVE SYMPTOMS IS ADDRESSED, BUT ONLY AFTER WORK HAS BEEN COMPLETED ON POSITIVE
SYMPTOMS

62. COMMON TECHNIQUES IN COGNITIVE
BEHAVIORAL THERAPY FOR SCHIZOPHRENIA
BEHAVIOURALSTRATEGIES
BEHAVIORAL ACTIVATION
PLEASANT ACTIVITY
SCHEDULING
RELAXATION/STRESS
REDUCTION
SELF-MONITORING
BEHAVIORAL
EXPERIMENTS
BEHAVIORAL CONTROL
STRATEGIES (E.G.,
DISTRACTION)
COGNITIVESTRATEGIES/COGNITIVE
RESTRUCTURING
IDENTIFYING AUTOMATIC
THOUGHTS
HYPOTHESIS TESTING
IDENTIFYING
ALTERNATIVE
EXPLANATIONS
EXPLORING EVIDENCE
COGNITIVE CONTROL
STRATEGIES

63. FAMILIES AND EXPRESSED EMOTIONS
• HIGH LEVELS OF CRITICISM, HOSTILITY OR OVER INVOLVEMENT HAVE
MORE FREQUENT RELAPSES.
• THE THREE ATTITUDE PERTAINING TO EXPRESSED EMOTION ARE
KNOWN AS HOSTILE, CRITICAL AND EMOTIONAL OVER-
INVOLVEMENT.
• THE RELATIVES INFLUENCE THE OUTCOME OF THE DISORDER
THROUGH NEGATIVE COMMENTS AND NONVERBAL ACTIONS.
• THE STRESS FROM THE FAMILY FOR THE PATIENT TO RECOVER AND
END CERTAIN BEHAVIOUR CAUSES THE PATIENT TO RELAPSE BACK.

64. PERSONAL THERAPY
• A FLEXIBLE TYPE OF PSYCHOTHERAPY CALLED PERSONAL THERAPY IS A RECENTLY
DEVELOPED FORM OF INDIVIDUAL TREATMENT FOR SCHIZOPHRENIA PATIENTS.
• ITS OBJECTIVE IS TO ENHANCE PERSONAL AND SOCIAL ADJUSTMENT AND TO
FORESTALL RELAPSE.
• IT IS A SELECT METHOD USING SOCIAL SKILLS AND RELAXATION EXERCISES,
PSYCHOEDUCATION, SELF-REFLECTION, SELF-AWARENESS, AND EXPLORATION OF
INDIVIDUAL VULNERABILITY TO STRESS.
• THE THERAPIST PROVIDES A SETTING THAT STRESSES ACCEPTANCE AND EMPATHY.
• PATIENTS RECEIVING PERSONAL THERAPY SHOW IMPROVEMENT IN SOCIAL
ADJUSTMENT (A COMPOSITE MEASURE THAT INCLUDES WORK PERFORMANCE,
LEISURE, AND INTERPERSONAL RELATIONSHIPS) AND HAVE A LOWER RELAPSE
RATE AFTER 3 YEARS THAN PATIENTS NOT RECEIVING PERSONAL THERAPY.

65. DIALECTICAL BEHAVIOUR THERAPY
• THIS FORM OF THERAPY, WHICH COMBINES COGNITIVE AND
BEHAVIORAL THEORIES IN BOTH INDIVIDUAL AND GROUP SETTINGS,
HAS PROVED USEFUL IN BORDERLINE STATES AND MAY HAVE BENEFIT
IN SCHIZOPHRENIA.
• EMPHASIS IS PLACED ON IMPROVING INTERPERSONAL SKILLS IN THE
PRESENCE OF AN ACTIVE AND EMPATHIC THERAPIST.

66. VOCATIONAL THERAPY
• A VARIETY OF METHODS AND SETTINGS ARE USED TO HELP PATIENTS
REGAIN OLD SKILLS OR DEVELOP NEW ONES.
• THESE INCLUDE :
• SHELTERED WORKSHOPS
• JOB CLUBS
• PART-TIME OR TRANSITIONAL EMPLOYMENT PROGRAMS.
• ENABLING PATIENTS TO BECOME GAINFULLY EMPLOYED IS BOTH A MEANS
TOWARD, AND A SIGN OF, RECOVERY.
• MANY SCHIZOPHRENIA PATIENTS ARE CAPABLE OF PERFORMING HIGH-
QUALITY WORK DESPITE THEIR ILLNESS.
• OTHERS MAY EXHIBIT EXCEPTIONAL SKILL OR EVEN BRILLIANCE IN A
LIMITED FIELD AS A RESULT OF SOME IDIOSYNCRATIC ASPECT OF THEIR
DISORDER.

67. TOKEN ECONOMY
• TOKEN ECONOMIES ARE BEHAVIORAL REINFORCEMENT PROGRAMS BASED
ON THE PRINCIPLES OF SOCIAL LEARNING.
• THEY ARE USUALLY EMPLOYED IN INPATIENT OR RESIDENTIAL SETTINGS WITH
THE DUAL GOALS OF
• MANAGING PATIENTS' BEHAVIORS WHILE THEY ARE IN THE HOSPITAL OR FACILITY
• PREPARING THEM TO BE ABLE TO FUNCTION BETTER IN OTHER, PRESUMABLY LESS
RESTRICTIVE AND LESS STRUCTURED SETTINGS.
• THE KEY ELEMENTS OF TOKEN ECONOMIES ARE:
1. IDENTIFICATION OF “TARGET BEHAVIORS” THAT ARE CONSIDERED
IMPORTANT/DESIRABLE FOR ALL PATIENTS
2. EARNING POINTS OR TOKENS FOR ENGAGING IN THESE BEHAVIORS
3. REDEEMING THE POINTS IN EXCHANGE FOR MATERIAL ITEMS OR PRIVILEGES
4. PARTICIPATION BY ALL PATIENTS IN THE TREATMENT SETTING.

69. ARTS THERAPY
• ONE SHOULD CONSIDER OFFERING ARTS THERAPIES TO ALL PEOPLE WITH PSYCHOSIS OR SCHIZOPHRENIA, PARTICULARLY
FOR THE ALLEVIATION OF NEGATIVE SYMPTOMS.
• THIS CAN BE STARTED EITHER DURING THE ACUTE PHASE OR LATER, INCLUDING IN INPATIENT SETTINGS.
• ARTS THERAPIES SHOULD BE PROVIDED BY A HEALTH AND CARE PROFESSIONS COUNCIL REGISTERED ARTS THERAPIST WITH
PREVIOUS EXPERIENCE OF WORKING WITH PEOPLE WITH PSYCHOSIS OR SCHIZOPHRENIA.
• THE INTERVENTION SHOULD BE PROVIDED IN GROUPS UNLESS DIFFICULTIES WITH ACCEPTABILITY AND ACCESS AND
ENGAGEMENT INDICATE OTHERWISE.
• ARTS THERAPIES SHOULD COMBINE PSYCHOTHERAPEUTIC TECHNIQUES WITH ACTIVITY AIMED AT PROMOTING CREATIVE
EXPRESSION, WHICH IS OFTEN UNSTRUCTURED AND LED BY THE SERVICE USER.
• AIMS OF ARTS THERAPIES SHOULD INCLUDE:
• ENABLING PEOPLE WITH PSYCHOSIS OR SCHIZOPHRENIA TO EXPERIENCE THEMSELVES DIFFERENTLY AND TO DEVELOP NEW WAYS OF
RELATING TO OTHERS
• HELPING PEOPLE TO EXPRESS THEMSELVES AND TO ORGANISE THEIR EXPERIENCE INTO A SATISFYING AESTHETIC FORM
• HELPING PEOPLE TO ACCEPT AND UNDERSTAND FEELINGS THAT MAY HAVE EMERGED DURING THE CREATIVE PROCESS (INCLUDING, IN SOME
CASES, HOW THEY CAME TO HAVE THESE FEELINGS) AT A PACE SUITED TO THE PERSON.

70. “SELF-ESTEEM IN FEMALES WITH SCHIZOPHRENIA USING GROUP ART THERAPY.”

71. REHABILITATION

72. INTRODUCTION TO SKILL
VIDEO TAPE DEMONSTRATION
ROLE PLAY
RESOURCE PROBLEM SOLVING
OUTCOME PROBLEM SOLVING
IN VIVO ASSIGNMENT
HOME WORK ASSIGNMENT
PARTICIPANTS ARE TOLD WHAT SKILL THEY WILL LEARN AND WHY THEY
SHOULD LEARN IT
EACH PARTICIPANT ROLEPLAYS THE SKILL THAT WAS DEMONSTRATED
PARTICIPANTS APPLY THE PROBLEM SOLVING METHOD TO RESOLVE
DIFFICULTIES THAT MAY OCCUR WHEN THEY TRY TO GET THE RESOURCES
PARTICIPANTS APPLY THE PROBLEM SOLVING METHOD TO RESOLVE
DIFFICULTIES THAT MAY OCCUR WHEN THEY IMPLEMENT THE SKILL AND THE
OUTCOMES ARE NOT AS EXPECTED
PARTICIPANTS GENERALIZE WHAT THEY HAVE LEARNT BY PRACTICING THE
SKILL OUTSIDE THE LEARNING ENVIORNMENT
PARTICIPANTS GENERALIZE WHAT THEY HAVE LEARNT BY EITHER PRACTICING
OR COMPLETING A RELATED TASK ON THEIR OWN
VIDEOTAPED DEMONSTRATION OF THE SKILL THAT IS STOPPED PERIODICALLY
S
T
E
P
S

73. SUBSTANCE ABUSE REHABILITATION
• SUBSTANCE ABUSE IS THE MOST COMMON AND CLINICALLY SIGNIFICANT
COMORBIDITY WITH SCHIZOPHRENIA.
• APPROXIMATELY 50 PERCENT OF ADULTS WITH SCHIZOPHRENIA HAVE AT
LEAST ONE CO-OCCURRING SUBSTANCE ABUSE AND ARE THEREFORE
CONSIDERED DUALLY DIAGNOSED.
• SUBSTANCE USE DISORDERS COMPLICATE THEIR LIVES IN MYRIAD WAYS,
LEADING TO INCREASED SYMPTOMS, RELAPSES, HOSPITALIZATIONS,
VIOLENCE, INCARCERATION, UNSTABLE HOUSING, HOMELESSNESS,
VICTIMIZATION, FAMILY PROBLEMS, AND SERIOUS MEDICAL PROBLEMS SUCH
AS HIV AND HEPATITIS.

74. • ADDICTION TO NICOTINE IS THE MOST COMMON FORM OF
SUBSTANCE ABUSE IN PEOPLE WITH SCHIZOPHRENIA.
• THEY ARE ADDICTED TO NICOTINE AT THREE TIMES THE RATE OF THE
GENERAL POPULATION (75 TO 90 PERCENT VS. 25 TO 30 PERCENT).
- http://www.nimh.nih.gov/health/publications/schizophrenia/index.shtml

75. • ONE SHOULD CONSIDER ONE OF THE FOLLOWING TO HELP PEOPLE STOP SMOKING:
• NICOTINE REPLACEMENT THERAPY (USUALLY A COMBINATION OF TRANSDERMAL PATCHES
WITH A SHORT-ACTING PRODUCT SUCH AS AN INHALATOR, GUM, LOZENGES OR SPRAY) FOR
PEOPLE WITH PSYCHOSIS OR SCHIZOPHRENIA OR
• BUPROPION FOR PEOPLE WITH A DIAGNOSIS OF SCHIZOPHRENIA OR
• VARENICLINE FOR PEOPLE WITH PSYCHOSIS OR SCHIZOPHRENIA.
• HOWEVER PEOPLE TAKING BUPROPION OR VARENICLINE SHOULD BE WARNED THAT
THERE IS AN INCREASED RISK OF ADVERSE NEUROPSYCHIATRIC SYMPTOMS AND
ONE HAS TO MONITOR THEM REGULARLY, PARTICULARLY IN THE FIRST 2–3 WEEKS.
[NEW 2014]
• FOR PEOPLE IN INPATIENT SETTINGS WHO DO NOT WANT TO STOP SMOKING, OFFER
NICOTINE REPLACEMENT THERAPY TO HELP THEM TO REDUCE OR TEMPORARILY
STOP SMOKING. [NEW 2014]
©NICE clinical guideline

76. TECHNIQUES
• INTEGRATION
• STAGE-WISE INTERVENTIONS
• ASSERTIVE OUTREACH
• MOTIVATIONAL INTERVENTIONS
• COUNSELING
• SOCIAL SUPPORT INTERVENTIONS

77. SOME COMMON FACTORS ASSOCIATED WITH
PSYCHOTIC RELAPSE
• ANTIPSYCHOTICS NOT COMPLETELY EFFECTIVE.
• ‘NONCOMPLIANCE’ – INCONSISTENT ANTIPSYCHOTIC MEDICATION
USE.
• POOR FAMILY ECONOMICAL STATUS.
• STRESSFUL LIFE EVENTS / HOME ENVIORNMENT [ EXPRESSED
EMOTION – HOSTILITY, CRITICISM, OVERINVOLVEMET]
• SUBSTANCE ABUSE

78. TREATMENT RESISTANT CASES

79. WHICH CASES ARE REGARDED AS TREATMENT RESISTANT ?
2 ANTIPSYCHOTIC TRIALS (400–600 MG CPZ EQUIVALENTS PER DAY) FOR 4 TO 6 WEEKS WITH NO
CLINICAL IMPROVEMENT,
 NO PERIOD OF GOOD SOCIAL OR OCCUPATIONAL FUNCTIONING FOR >5 YEARS,
 BPRS TOTAL SCORE > 45, AND A SCORE OF >4 ON 2 OF 4 POSITIVE ITEMS.
CGI >OR = 4 (MODERATELY ILL)

80. • NO IMPROVEMENT AFTER 6 WEEKS OF TREATMENT WITH HALOPERIDOL
(UP TO 60 MG/D OR HIGHER)
• IMPROVEMENT WILL STILL BE DEFINED AS TREATMENT RESISTANCE
A 20% REDUCTION OF THE BPRS AS COMPARED WITH THE LEVEL OF SEVERITY DEFINED BY THE
ACTUAL CRITERIA
AND/OR A POST TREATMENT CGI OF ≤ 3 OR A BPRS ≤ 35.

81. STRATEGY FOR TREATMENT OF INADEQUATE RESPONSE TO
CONVENTIONAL ANTIPSYCHOTIC DRUG THERAPY
• 1. OPTIMIZE TRIAL OF ANTIPSYCHOTIC MEDICATION.
• A. USE 300-600 MG CHLORPROMAZINE EQUIVALENTS FOR 6-8
WEEKS.
• B. CONSIDER A TRIAL OF DEPOT NEUROLEPTIC, IF NOT YET DONE.
• C. TREAT ANY UNDERLYING EXTRAPYRAMIDAL SYMPTOMS (EPS).
• I. CONSIDER DOSE REDUCTION IF EPS IS PRESENT.
• II. ADD ADJUNCT ANTICHOLINERGIC MEDICATION, IF
NEEDED.
SOURCE.—ADAPTED FROM FRANCES ET AL. SCHIZOPHRENIA BULLETIN, VOL. 23, NO. 4

82. • IF NO RESPONSE TO ABOVE, SWITCH MEDICATION TO NOVEL
ANTIPSYCHOTIC.
• CROSS-TAPER OFF CONVENTIONAL ANTIPSYCHOTICS FOR 2-4
WEEKS.
• CONTINUE ANTICHOLINERGIC MEDICATION UNTIL CONVENTIONAL
ANTIPSYCHOTICS HAVE BEEN DISCONTINUED AT LEAST 2 WEEKS.
• CHOICES INCLUDE THE FOLLOWING:
• A. RISPERIDONE, 2-6 MG PER DAY FOR 6-8 WEEKS.
• B. OLANZAPINE, 15-25 MG PER DAY FOR 6-8 WEEKS.
• C. SERTINDOLE, 20-24 MG PER DAY FOR 6-8 WEEKS (WHEN AVAILABLE).
• D. QUETIAPINE, 300-450 MG PER DAY FOR 6-8 WEEKS(WHEN AVAILABLE)
SOURCE.—ADAPTED FROM FRANCES ET AL. SCHIZOPHRENIA BULLETIN, VOL. 23, NO. 4

83. • 3. IF NO RESPONSE TO ABOVE, SWITCH TO CLOZAPINE.
• A. INCREASE GRADUALLY TO 200-400 MG FOR 4-6 WEEKS.
• B. IF NO RESPONSE, INCREASE GRADUALLY TO 500-600 MG FOR 6 WEEKS.
• C. IF NO RESPONSE, INCREASE GRADUALLY TO 700-900 MG FOR 6 WEEKS.
• CAREFULLY MONITOR FOR SIDE EFFECTS.
• DO NOT INCREASE DOSE IF MYOCLONUS IS PRESENT.
SOURCE.—ADAPTED FROM FRANCES ET AL. SCHIZOPHRENIA BULLETIN, VOL. 23, NO. 4

84. • IF NO RESPONSE TO CLOZAPINE, DISCONTINUE.
• RE-INSTITUTE BEST PRIOR DRUG THERAPY.
• CONSIDER ADJUNCT MEDICATION,
• I. LITHIUM.
• II. ANTICONVULSANTS.(A). VALPROIC ACID.(B). CARBAMAZAPINE
• III. BENZODIAZEPINES.
• IV. PROPRANOLOL.
• V. ANTIDEPRESSANTS.
• VI. HIGHER DOSES OF CONVENTIONAL ANTIPSYCHOTICS.
SOURCE.—ADAPTED FROM FRANCES ET AL. SCHIZOPHRENIA BULLETIN, VOL. 23, NO. 4

85. • IF NO RESPONSE TO BEST PRIOR DRUG THERAPY OR ADJUNCT
MEDICATIONS, CONSIDER THIRD-LINE STRATEGIES.
• A. ELECTROCONVULSIVE TREATMENT.
• B. RESERPINE.
SOURCE.—ADAPTED FROM FRANCES ET AL. SCHIZOPHRENIA BULLETIN, VOL. 23, NO. 4

86. IMPORTANT NATIONAL & INTERNATIONAL
ORGANIZATIONS

87. NATIONAL ALLIANCE FOR THE MENTALLY ILL
• THE NATIONAL ALLIANCE FOR THE MENTALLY ILL (NAMI) AND SIMILAR
ORGANIZATIONS OFFER SUPPORT GROUPS FOR FAMILY MEMBERS AND
FRIENDS OF PATIENTS WHO ARE MENTALLY ILL AND FOR PATIENTS
THEMSELVES.
• THESE ORGANIZATIONS OFFER EMOTIONAL AND PRACTICAL ADVICE
ABOUT OBTAINING CARE IN THE SOMETIMES COMPLEX HEALTH CARE
DELIVERY SYSTEM AND ARE USEFUL SOURCES TO WHICH TO REFER FAMILY
MEMBERS.
• NAMI HAS ALSO WAGED A CAMPAIGN TO DESTIGMATIZE MENTAL ILLNESS
AND TO INCREASE GOVERNMENT AWARENESS OF THE NEEDS AND RIGHTS
OF PERSONS WHO ARE MENTALLY ILL AND THEIR FAMILIES.

90. ASSERTIVE COMMUNITY TREATMENT
• THE ASSERTIVE COMMUNITY TREATMENT (ACT) PROGRAM WAS ORIGINALLY
DEVELOPED BY RESEARCHERS IN MADISON, WISCONSIN, IN THE 1970S, FOR THE
DELIVERY OF SERVICES FOR PERSONS WITH CHRONIC MENTAL ILLNESS.
• PATIENTS ARE ASSIGNED TO ONE MULTIDISCIPLINARY TEAM (CASE MANAGER,
PSYCHIATRIST, NURSE, GENERAL PHYSICIANS, ETC.).
• THE TEAM HAS A FIXED CASELOAD OF PATIENTS AND DELIVERS ALL SERVICES WHEN
AND WHERE NEEDED BY THE PATIENT, 24 HOURS A DAY, 7 DAYS A WEEK.
• THIS IS MOBILE AND INTENSIVE INTERVENTION THAT PROVIDES TREATMENT,
REHABILITATION, AND SUPPORT ACTIVITIES.
• THESE INCLUDE HOME DELIVERY OF MEDICATIONS, MONITORING OF MENTAL AND
PHYSICAL HEALTH, IN VIVO SOCIAL SKILLS, AND FREQUENT CONTACT WITH FAMILY
MEMBERS.
• THERE IS A HIGH STAFF-TO-PATIENT RATIO (1:12).
• ACT PROGRAMS CAN EFFECTIVELY DECREASE THE RISK OF REHOSPITALIZATION FOR
PERSONS WITH SCHIZOPHRENIA, BUT THEY ARE LABOR-INTENSIVE AND EXPENSIVE
PROGRAMS TO ADMINISTER.

91. SCHIZOPHRENIA AWARENESS DAY – MAY 24TH

92. CONCLUSION
• A THROUGH HISTORY SHOULD BE TAKEN TO EXAMINE THE EVIDENCES
TO FORMULATE THE MOST EFFECTIVE FORM OF MANAGEMENT.
• MANAGEMENT OF SCHIZOPHRENIA INCLUDES BOTH
PHARMACOLOGICAL & PSYCHOSOCIAL THERAPIES.
• INTEGRATION OF PSYCHOSOCIAL AND MEDICATION TREATMENTS IS THE
MOST EFFECTIVE FORM OF TREATMENT
• TREATMENT CAN ALLEVIATE SYMPTOMS, REDUCE DISTRESS AND
IMPROVE FUNCTIONING
• DELAYED TREATMENT WORSENS PROGNOSIS
• TREATMENT OF SCHIZOPHRENIA SHOULD BE DONE AS A TEAM WITH
PSYCHIATRIST, FAMILY & SOCIAL SUPPORT

93. THANK YOU