Integrated treatment of schizophrenia

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SCHIZOPHRENIA is a chronic, debilitating and stigmatizing neuropsychiatric disorder. The prevalence is estimated globally at around 0.4%, which equates to around 90,000 Australians, most of whom will be diagnosed in late adolescence or early adulthood and then live with the disease. illness for the rest of their lives.

This reality is illustrated by the recent report on mental health from the National Productivity Commission, which found schizophrenia to be the most debilitating and stigmatized mental illness. The annual cost of psychosis to Australia’s healthcare system is estimated at $ 6 billion, but that figure does not take into account the suffering and pain of individuals, their loved ones and the supportive community.

Symptom areas and treatments

Much of this suffering is due to the lack of knowledge of the cause (s) of the disorder and, more specifically, the absence of any intervention modifying the disease or course.

Current pharmacological and psychosocial treatments reduce the burden of symptoms and improve personal and social functioning; however, symptoms and functioning may vary independently. The basis of treatment is the use of antipsychotic drugs such as chlorpromazine, haloperidol and clozapine, which appeared 70 years ago. This class of drugs is effective for the symptoms of psychosis regardless of the etiology, and improves psychotic symptoms in about 70% of people with schizophrenia. For those who do not respond to conventional antipsychotic drugs, clozapine has demonstrable superiority, helping about half of these non-responders. But it is a Section 100 drug due to the risk of agranulocytosis and is associated with myocarditis and other life-threatening and serious side effects limiting its general use.

However, psychosis is only one symptomatic dimension of schizophrenia and, while it is essential to reduce the often distressing aspects of delusions and hallucinations and to improve disturbances in thinking, a complete return to levels of premorbid functioning is rare.

Instead, other clinical dimensions previously hidden behind psychosis become more apparent as treatment progresses. These include decreased cognition, anxiety, depression, suicidal tendencies, and substance abuse disorders. These symptom areas do not show a primary response to antipsychotic drugs and many of them, such as cognitive and depressive symptoms, may be exacerbated by treatment with antipsychotic drugs. A plausible reason for this concerns the common mechanism of action of conventional antipsychotic drugs in antagonism of dopamine D2 receptors. These receptors mediate cognitive, reward, affective and motivational neural pathways, so blocking the receptors decreases dopamine neurotransmission.

To avoid these deleterious results, there is a desperate need for new treatments and they are now on the horizon. A muscarinic receptor agonist showed significant improvement in positive and negative symptoms and a glycine transporter inhibitor improved cognitive symptoms – positive symptoms are changes in thoughts and feelings that are “added” to experiences. a person (for example, paranoia or hearing voices); “negative” symptoms reflect a decrease or loss of normal functions.

However, until new treatments become widely available, there are existing strategies to improve other areas of symptoms and functioning in schizophrenia.

The main one is the use of psychological and social interventions, including training in cognitive remediation, cognitive-behavioral and mindfulness therapies as well as individual professional support. In addition, the range of antipsychotic drugs has grown considerably over the past 15 years. These new agents have different pharmacological characteristics, such as partial agonism of dopamine D2 receptors which decreases potential adverse effects on dopamine pathways or decreased sedation induced by histamine H1 receptors.

Comprehensive care for people with schizophrenia and the role of the general practitioner

It is important to stress that people with schizophrenia have a complex set of issues, encompassing the symptoms of the disease itself, as well as social and occupational exclusion and associated economic hardship (here and here). Patients with schizophrenia experience significant stigma.

No single practitioner can handle all of these issues on their own, and a multidisciplinary approach is needed. Arguably, the general practitioner could be seen as the conductor of the orchestra of practitioners involved in the care of each patient, being responsible for the overall holistic management, monitoring of symptoms and side effects of medications as well. as well as the organization of appropriate referrals, as needed. Engagement with the family may also be part of the role of the general practitioner, although specialized family interventions require the contribution of trained practitioners.

The extent of symptoms and disabilities associated with schizophrenia is further aggravated by other psychiatric disorders (including depression and anxiety disorders), which are often missed in clinical practice and, therefore, too often under-treated. The general practitioner is in a good position to detect and manage these comorbidities, in particular when he sees the patients in a longitudinal way. Key suggestions include:

  • Do not assume that all patient symptoms and behaviors are due to schizophrenia; for example, social withdrawal may be due to negative symptoms, depression, or social anxiety.
  • Always ask focused, non-judgmental questions to get what is driving the behavior; for example, if you are trying to solicit depressive symptoms (as opposed to demoralization), ask about the main characteristics of overwhelming depressed mood and loss of interest in things, and then determine if the person can still light up and when she’s last enjoyed something. and / or laughed. Next, ask about associated characteristics, such as guilt and feelings of worthlessness and suicidality (these usually distinguish depression from demoralization or negative symptoms); and then on associated characteristics, such as sleep disturbances and change in appetite.
  • Always perform a risk assessment: The risk of suicide is considerably higher in people with schizophrenia than in the general population.
  • Treat comorbidities in their own right (eg, selective serotonergic antidepressants for major depression), but be aware of additive side effects (eg, sexual dysfunction) and potential interactions with antipsychotics (eg, fluvoxamine may increase serum clozapine levels).

The physical health problems associated with schizophrenia shorten lives and, unfortunately, the mortality gap between people with schizophrenia and those in the general population is widening. General practitioners can play a key role in both monitoring and intervention to reduce cardiovascular risk in their patients. Engaging the patient and, where appropriate, family members in a discussion about improving risk factors is a vital and ongoing task for all involved in the care of people with schizophrenia. Advice for general practitioners includes:

Finally, it is worth considering that the primary place of care for Australians with schizophrenia has shifted from old and large institutions to the community. This was largely a welcome decision, and generally people with schizophrenia are happier living in the community. However, they still experience stigma, unemployment and poverty and some fall through the cracks in terms of service delivery, ending up homeless or in the prison system. It is imperative that all those involved in the provision of mental health services work together effectively to try to prevent these unsatisfactory outcomes and to promote self-efficacy and recovery in people with schizophrenia. It’s a set of achievable goals.

Conclusion

Schizophrenia remains a devastating disorder for many affected people. Its impacts on cognitive and social functioning; its association with substance abuse, depression and anxiety; and the often poor response to treatment takes a heavy toll on individuals and their families. Too often this leads to suicide, homelessness, social isolation and unemployment, and furthermore, the disorder and its treatments often precipitate or worsen chronic physical health comorbidities, such as type 2 diabetes. New treatments for the wide variety of symptom areas are finally on the horizon. However, until they are generally available, optimizing current antipsychotic drugs and psychosocial interventions remains key.

Professor Suresh Sundram is Chairman and Head of the Department of Psychiatry at Monash University and Director of Research for the Mental Health Program, Monash Health, and the Asylum Seekers and Refugees Health Program at Cabrini. He has received advisory fees, advisory board fees, research assistance, speaker fees or travel assistance from: AstraZeneca, Bristol-Myers Squibb, Eli Lilly, GlaxoSmithKline, Janssen, Lundbeck, Otsuka, Pfizer , Roche, Sequirus, Servier; Medical Research Future Fund, National Board of Health and Medical Research (Aust), National Institute of Health Research (UK), One-in-Five Association; Australian Department of Home Affairs, Australian Human Rights Commission and United Nations High Commissioner for Refugees.

Professor David Castle is currently the inaugural Scientific Director of the Center for Complex Interventions (CCI) at the Center for Addiction and Mental Health in Toronto, Canada; and professor in the Department of Psychiatry at the University of Toronto. He has received research grants from Eli Lilly, Janssen Cilag, Roche, Allergen, Bristol-Myers Squibb, Pfizer, Lundbeck, AstraZeneca, Hospira; Travel assistance and fees for interviews and advice from Eli Lilly, Bristol-Myers Squibb, AstraZeneca, Lundbeck, Janssen Cilag, Pfizer, Organon, Sanofi-Aventis, Wyeth, Hospira, Servier, Seqirus; and is a current or past member of the Advisory Board of Lu AA21004: Lundbeck; Varenicline: Pfizer; Asenapine: Lundbeck; Aripiprazole LAI: Lundbeck; Lisdexamfetamine: Shire; Lurasidone: Servier; Brexpiprazole: Lundbeck; Treatment-resistant depression: LivaNova; Cariprazine: Seqirus.

The statements or opinions expressed in this article reflect the opinions of the authors and do not represent the official policy of WADA, the MJA Where InSight + unless otherwise stated.


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