Treatments for Schizophrenia and Other Severe Mental Disorders

1. Treatments for Schizophrenia and Other Severe Mental Disorders Chapter 15 Slides & Handouts by Karen Clay Rhines, Ph.D. American Public University System

2. How Are Schizophrenia and Other Severe Mental Disorders Treated? • For much of human history, people with schizophrenia and other severe mental disorders were considered beyond help • Though schizophrenia is still extremely difficult to treat, the discovery of antipsychotic drugs has enabled people with the disorder to think clearly and profit from psychotherapies • Each of the models offers treatments for schizophrenia, and all have been influential at one time or another Comer, Abnormal Psychology, 8e DSM-5 Update

3. How Are Schizophrenia and Other Severe Mental Disorders Treated? • It is important to keep in mind that throughout much of the 20th century, the label “schizophrenia” was assigned to most people with psychosis • Clinical theorists now realize that many people with psychotic symptoms are instead displaying other disorders and were inaccurately diagnosed • As such, discussions of past and current approaches to schizophrenia often apply to other severe mental illnesses as well Comer, Abnormal Psychology, 8e DSM-5 Update

4. Institutional Care in the Past • For more than half of the 20th century, people with schizophrenia were institutionalized in public mental hospitals • Because patients failed to respond to traditional therapies, the primary goals of the hospitals were to restrain them and give them food, shelter, and clothing Comer, Abnormal Psychology, 8e DSM-5 Update

5. Institutional Care in the Past • The move toward institutionalization began in 1793 with the practice of “moral treatment” • Hospitals were located in isolated areas to protect patients from the stresses of daily life and to offer them a healthful psychological environment Comer, Abnormal Psychology, 8e DSM-5 Update

6. Institutional Care in the Past • States throughout the U.S. were required by law to establish public mental institutions (state hospitals) for patients who could not afford private care • Unfortunately, problems with overcrowding, understaffing, and poor patient outcomes led to loss of individual care and the creation of “back wards” – human warehouses filled with hopelessness Comer, Abnormal Psychology, 8e DSM-5 Update

7. Institutional Care in the Past • Many patients not only failed to improve under these conditions but developed additional symptoms, apparently as a result of the institutionalization itself • The most common pattern of decline was called the social breakdown syndrome, which involved: • Extreme withdrawal, anger, and physical aggressiveness • Loss of interest in personal appearance and functioning Comer, Abnormal Psychology, 8e DSM-5 Update

8. Institutional Care Takes a Turn for the Better • In the 1950s, clinicians developed two institutional approaches that brought some hope to chronic patients: • Milieu therapy • Based on humanistic principles • Token economy programs • Based on behavioral principles • These approaches particularly helped improve the personal care and self-image of patients, problem areas that were worsened by institutionalization Comer, Abnormal Psychology, 8e DSM-5 Update

9. Institutional Care Takes a Turn for the Better • Milieu therapy • The premise is that institutions can help patients make clinical progress by creating a social climate (“milieu”) that promotes productive activity, self-respect, and individual responsibility • Milieu-style programs have been set up in institutions throughout the Western world with moderate success • Research has shown that patients with schizophrenia and other severe mental disorders in milieu programs often leave the hospital at higher rates than patients receiving custodial care Comer, Abnormal Psychology, 8e DSM-5 Update

10. Institutional Care Takes a Turn for the Better • The token economy • Based on operant conditioning principles, token economies are used in institutions to change the behavior of these individuals • Patients are rewarded when they behave in socially acceptable ways and are not rewarded when they behave unacceptably • Immediate rewards are tokens that can later be exchanged for food, cigarettes, privileges, and other desirable objects • Acceptable behaviors likely to be targeted include care for oneself and one’s possessions, going to a work program, speaking normally, following ward rules, and showing self-control Comer, Abnormal Psychology, 8e DSM-5 Update

11. Institutional Care Takes a Turn for the Better • The token economy • Researchers have found that token economies help reduce psychotic and related behavior • However, questions have been raised about such programs: • Many research studies have been uncontrolled; instead of patients being randomly assigned to groups, a whole ward will participate in the program • Are such programs ethical and legal? Aren’t all humans entitled to basic rights, some of which are compromised in a strict token economy system? Comer, Abnormal Psychology, 8e DSM-5 Update

12. Institutional Care Takes a Turn for the Better • The token economy • Questions have been raised about such programs: • Are such programs truly effective? For example, patients may change overt behaviors but not underlying psychotic beliefs • Transitioning from a token economy system to community living may be difficult for patients Comer, Abnormal Psychology, 8e DSM-5 Update

13. Institutional Care Takes a Turn for the Better • Token economy programs are no longer as popular as they once were but they are still used in many mental hospitals, usually along with medication • This approach has also been applied to other clinical problems Comer, Abnormal Psychology, 8e DSM-5 Update

14. Antipsychotic Drugs • While milieu therapy and token economies helped improve treatment outcomes, it was the discovery of antipsychotic drugs in the 1950s that revolutionized treatment for those suffering from schizophrenia Comer, Abnormal Psychology, 8e DSM-5 Update

15. Antipsychotic Drugs • The discovery of antipsychotic medications dates back to the 1940s, when researchers developed antihistamine drugs for allergies • It was discovered that one group of antihistamines, phenothiazines, could be used to calm patients about to undergo surgery • Psychiatrists tested one of the drugs, chlorpromazine, on 6 patients with psychosis and observed a sharp reduction in their symptoms • In 1954, chlorpromazine (under the trade name Thorazine) was approved for sale in the U.S. as an antipsychotic drug Comer, Abnormal Psychology, 8e DSM-5 Update

16. Antipsychotic Drugs • Since the discovery of the phenothiazines, other kinds of antipsychotic drugs have been developed • Those developed throughout the 1960s, 1970s, and 1980s are now referred to as “conventional” antipsychotic drugs • These drugs are also known as neuroleptic drugs, because they often produce undesired movement effects similar to symptoms of neurological diseases • Drugs developed in recent years are known as “atypical” or “second-generation” antipsychotics Comer, Abnormal Psychology, 8e DSM-5 Update

17. How Effective Are Antipsychotic Drugs? • Research has shown that antipsychotic drugs reduce symptoms in at least 65% of patients diagnosed with schizophrenia • In direct comparisons, drugs appear to be more effective than any other approach used alone • In most cases, the drugs produce the maximum level of improvement within the first six months of treatment • Symptoms may return if patients stop taking the drugs too soon Comer, Abnormal Psychology, 8e DSM-5 Update

18. How Effective Are Antipsychotic Drugs? • Antipsychotic drugs, particularly the conventional ones, reduce the positive symptoms of schizophrenia more completely, or at least more quickly, than the negative symptoms • Correspondingly, people who display largely positive symptoms generally have better rates of recovery than those with primarily negative symptoms Comer, Abnormal Psychology, 8e DSM-5 Update

19. How Effective Are Antipsychotic Drugs? • Although the use of such drugs is now widely accepted, patients often dislike the powerful effects of the drugs, and some refuse to take them Comer, Abnormal Psychology, 8e DSM-5 Update

20. The Unwanted Effects of Conventional Antipsychotic Drugs • In addition to reducing psychotic symptoms, conventional antipsychotic drugs sometimes produce disturbing movement problems • These are called “extrapyramidal effects” because they appear to be caused by the drugs’ impact on the extrapyramidal areas of the brain Comer, Abnormal Psychology, 8e DSM-5 Update

21. The Unwanted Effects of Conventional Antipsychotic Drugs • The most common of these effects are Parkinsonian symptoms, reactions that closely resemble features of the neurological disorder Parkinson’s disease, including: • Muscle tremor and rigidity • Movements of the face, neck, tongue, and back • Great restlessness, agitation, and discomfort in the limbs Comer, Abnormal Psychology, 8e DSM-5 Update

22. The Unwanted Effects of Conventional Antipsychotic Drugs • The Parkinsonian and related symptoms seem to be the result of medication-induced reductions of dopamine activity in the basal ganglia and substantianigra, parts of the brain that coordinate movement and posture • In most cases, the symptoms can be reversed if an anti-Parkinsonian drug is taken along with the antipsychotic • Sometimes the dosage must be decreased or the medication must be halted altogether Comer, Abnormal Psychology, 8e DSM-5 Update

23. The Unwanted Effects of Conventional Antipsychotic Drugs • In as many as 1% of patients, particularly elderly ones, conventional antipsychotic drugs produce neuroleptic malignant syndrome – a severe, potentially fatal reaction • Symptoms include muscle rigidity, fever, altered consciousness, and improper functioning of the autonomic nervous system • As soon as the syndrome is recognized, drug use is discontinued and each symptom is treated medically • Individuals may also be given dopamine-enhancing drugs Comer, Abnormal Psychology, 8e DSM-5 Update

24. The Unwanted Effects of Conventional Antipsychotic Drugs • A more difficult side effect of conventional antipsychotic drugs appears up to 1 year after starting the medication • This reaction, called tardivedyskinesia, involves writhing or tic-like involuntary movements, usually of the mouth, lips, tongue, legs, or body • It affects more than 10% of those taking the drugs and patients over 50 years of age seem to be at greater risk • Tardivedyskinesia can be difficult, sometimes impossible, to eliminate Comer, Abnormal Psychology, 8e DSM-5 Update

25. The Unwanted Effects of Conventional Antipsychotic Drugs • Since learning of the unwanted side effects of conventional antipsychotic drugs, clinicians have become more cautious in their prescription practices • They try to prescribe the lowest effective dose • They gradually reduce or stop medication weeks or months after the patient begins functioning normally Comer, Abnormal Psychology, 8e DSM-5 Update

26. Newer Antipsychotic Drugs • In recent years, new antipsychotic drugs have been developed • Examples: Clozaril, Risperdal, Zyprexa, Seroquel, Geodon, and Abilify Comer, Abnormal Psychology, 8e DSM-5 Update

27. Newer Antipsychotic Drugs • These new drugs are called “atypical” because their biological operation differs from that of conventional antipsychotics • They appear more effective than conventional antipsychotic drugs, especially for negative symptoms • They cause few extrapyramidal side effects and seem less likely to case tardive dyskinesia Comer, Abnormal Psychology, 8e DSM-5 Update

28. Newer Antipsychotic Drugs • They do, however, have serious problems as well: • They carry a risk of agranulocytosis, a life-threatening drop in white blood cells • They also may cause weight gain, dizziness, and significant elevations in blood sugar Comer, Abnormal Psychology, 8e DSM-5 Update

29. Psychotherapy • Before the discovery of antipsychotic drugs, psychotherapy was not an option for people with schizophrenia • Most were too far removed from reality to profit from psychotherapy Comer, Abnormal Psychology, 8e DSM-5 Update

30. Psychotherapy • Today, psychotherapy is successful in many more cases of schizophrenia • By helping to relieve their thought and perceptual disturbances, antipsychotic drugs allow people with schizophrenia to learn about their disorder, participate in therapy, think more clearly, and make changes in their behavior Comer, Abnormal Psychology, 8e DSM-5 Update

31. Psychotherapy • The most helpful forms of psychotherapy include cognitive-behavioral therapy and two broader sociocultural therapies: family therapy and social therapy • These approaches are often combined Comer, Abnormal Psychology, 8e DSM-5 Update

32. Psychotherapy • Cognitive-behavioral therapy • An increasing number of clinicians employ techniques that seek to change how individuals view and react to their hallucinatory experiences, including: • Provide education and evidence of the biological causes of hallucinations • Help clients learn about the “comings and goings” of their own hallucinations and delusions • Challenge clients’ inaccurate ideas about the power of their hallucinations Comer, Abnormal Psychology, 8e DSM-5 Update

33. Psychotherapy • Cognitive-behavioral therapy • An increasing number of clinicians employ techniques that seek to change how individuals view and react to their hallucinatory experiences, including: • Teach clients to reattribute and more accurately interpret their hallucinations • Teach techniques for coping with their unpleasant sensations Comer, Abnormal Psychology, 8e DSM-5 Update

34. Psychotherapy • Cognitive-behavioral therapy • New-wave cognitive-behavioral therapies also help clients to accept their streams of problematic thoughts • These techniques help patients gain a greater sense of control, become more functional, and move forward in life • Studies indicate that these various techniques are often very helpful Comer, Abnormal Psychology, 8e DSM-5 Update

35. Psychotherapy • Family therapy • Over 50% of persons recovering from schizophrenia and other severe disorder live with family members • This creates significant family stress • Those who live with relatives who display high levels of expressed emotion are at greater risk for relapse than those who live with more positive or supportive families Comer, Abnormal Psychology, 8e DSM-5 Update

36. Psychotherapy • Family therapy • Family therapy attempts to address such issues, create more realistic expectations, and provide psychoeducation about the disorder • Families may also turn to family support groups and family psychoeducation programs • Although research has yet to determine the usefulness of these groups, the approach has become popular Comer, Abnormal Psychology, 8e DSM-5 Update

37. Psychotherapy Comer, Abnormal Psychology, 8e DSM-5 Update • Social Therapy • Many clinicians believe that the treatment of people with schizophrenia should include techniques that address social and personal difficulties in the clients’ lives • These include: practical advice, problem solving, decision making, social skills training, medication management, employment counseling, financial assistance, and housing • Research finds that this approach reduces rehospitalization

38. The Community Approach • The community approach is the broadest approach for the treatment of schizophrenia and other severe mental disorders • In 1963, Congress passed the Community Mental Health Act, which said that patients should be able to receive care within their own communities, rather than being transported to institutions far from home • This Act led to massive deinstitutionalization of patients • Unfortunately, community care was (and is) inadequate for their care • The result is a “revolving door” syndrome Comer, Abnormal Psychology, 8e DSM-5 Update

39. What Are the Features of Effective Community Care? • People recovering from schizophrenia and other severe disorders need medication, psychotherapy, help in handling daily pressures and responsibilities, guidance in making decisions, training in social skills, residential supervision, and vocational counseling • This combination of services sometimes is called assertive community treatment • Other key features are… Comer, Abnormal Psychology, 8e DSM-5 Update

40. What Are the Features of Effective Community Care? • Coordinated services • Community mental health centers provide medications, psychotherapy, and inpatient emergency care • Coordination of services is especially important for mentally ill chemical abusers (MICAs) • Short-term hospitalization • If treatment on an outpatient basis is unsuccessful, patients may be transferred to short-term hospital programs • After being hospitalized for up to a few weeks, patients are released to aftercare programs for follow-up in the community Comer, Abnormal Psychology, 8e DSM-5 Update

41. What Are the Features of Effective Community Care? • Partial hospitalization • If patient needs fall between full hospitalization and outpatient care, day center programs may be effective • These programs provide daily supervised activities and programs to improve social skills • Another kind of institution that has become popular is the semihospital, or residential crisis center – houses or other structures in the community that provide 24-hour nursing care for those with severe mental disorders Comer, Abnormal Psychology, 8e DSM-5 Update

42. What Are the Features of Effective Community Care? • Supervised residences • Halfway houses (or group homes) provide shelter and supervision for those patients who are unable to live alone or with their families, but who do not require hospitalization • Staff are usually paraprofessionals • Houses are run with a milieu therapy philosophy • These programs help those with schizophrenia adjust to community life and avoid rehospitalization Comer, Abnormal Psychology, 8e DSM-5 Update

43. What Are the Features of Effective Community Care? • Occupational training and support • Paid employment provides income, independence, self-respect, and the stimulation of working with others • Many people recovering from schizophrenia and other severe mental disorders receive occupational training in a sheltered workshop – a supervised workplace for employees who are not ready for competitive or complicated jobs • An alternative work opportunity for individuals with severe disorders is supported employment Comer, Abnormal Psychology, 8e DSM-5 Update

44. How Has Community Treatment Failed? • There is no doubt that effective community programs can help people with schizophrenia and other severe mental disorders recover • However, fewer than half of all people who need them receive appropriate community mental health services • In any given year, 40% to 60% of all people with schizophrenia and other severe mental disorders receive no treatment at all • Two factors are primarily responsible: • Poor coordination of services • Shortage of services Comer, Abnormal Psychology, 8e DSM-5 Update

45. How Has Community Treatment Failed? • Poor coordination of services • Mental health agencies in a community often fail to communicate with one another • To combat this problem, a growing number of community therapists have become case managers for their clients • Case managers offer therapy and advice, teach problem-solving and social skills, and ensure compliance with medications • Case managers also try to coordinate available community services for their clients, guide them through the system and protect their legal rights Comer, Abnormal Psychology, 8e DSM-5 Update

46. How Has Community Treatment Failed? • Shortage of services • The number of community programs available to people with severe mental disorders falls woefully short • The centers that do exist generally fail to provide adequate services for people with severe disorders • While there are various reasons for these shortages, the primary one is economic Comer, Abnormal Psychology, 8e DSM-5 Update

47. What Are the Consequences of Inadequate Community Treatment? • When community treatment fails, many people suffering from schizophrenia and other severe mental disorders receive no treatment at all • Many return to their families and receive medication and perhaps emotional and financial support, but little else in the way of treatment Comer, Abnormal Psychology, 8e DSM-5 Update

48. What Are the Consequences of Inadequate Community Treatment? • Around 8% of patients enter an alternative care facility (such as a nursing home), where they receive custodial care and medication • As many as 18% are placed in privately run residences where supervision is provided by untrained individuals • Another 34% of patients are placed in single-room occupancy hotels, generally in rundown environments, where they survive on government disability payments Comer, Abnormal Psychology, 8e DSM-5 Update

49. What Are the Consequences of Inadequate Community Treatment? • Finally, a great number of people suffering from schizophrenia become homeless • Approximately one-third of the homeless people in America have a severe mental disorder, commonly schizophrenia Comer, Abnormal Psychology, 8e DSM-5 Update

50. The Promise of Community Treatment • Despite these very serious problems, proper community care has shown great potential for assisting in recovery from schizophrenia and other severe disorders • In addition, a number of national interest groups, including the National Alliance on Mental Illness (NAMI), have formed to push for better community treatment Comer, Abnormal Psychology, 8e DSM-5 Update