Thursday, 24 May 2018

Schizophrenia :Risk Factors, Treatment, and Antipsychotics

Schizophrenia: Risk Factors and Treatment



Schizophrenia :Treatment


Potential Psychosocial risk factors for Schizophrenia  include: 

  • Childhood diversity:
    • Emotional abuse
    • Physical abuse
    • Sexual abuse
    • Ignorance
    • Death of parents.

  • Migration, especially becoming a member of a lower socio-economic ethnic minority in an affluent nation.

  • Being born in the urban area.

  • Any life event full of stress 

  • Illicit Substance Use- Drugs which increase Dopamine activity (Cocaine, Amphetamine, Cannabis)  can cause psychotic symptoms similar to Schizophrenia. 

However, a greater proportion of patients with Schizophrenia use illicit drugs compared to the general population. While these drugs can cause psychotic symptoms,  it is unlikely that they actually cause Schizophrenia, but, in vulnerable individuals, they can-

    • Increase the frequency of relapse in a patient with Schizophrenia.

    • Bring forward the age of onset of Schizophrenia.

    • Can also interfere with the effectiveness of antipsychotics.



Treatment of Schizophrenia- General Principles


Antipsychotics (Neuroleptics) are the mainstay of treatment for Schizophrenia. If available, Cognitive Behaviour Therapy (CBT) may be used in addition to antipsychotic for treatment-resistant psychotic symptoms.



In severe, chronic Schizophrenia, the patient would need psychosocial rehabilitation.


Rationale for Anti-Psychotics

Dopamine Hypothesis of Schizophrenia: This states that Schizophrenia is due to an excess of Dopamine in the brain, so by decreasing the activity of Dopamine, Schizophrenia can be treated. 



Classification of Anti-Psychotics is as follows:

 1) Older / First Generation /Typical:
    
       a)    Chlorpromazine

       b)    Haloperidol

2) Newer / Second Generation / Atypical:

         a) Risperidone

         b) Olanzapine

         c) Quetiapine

         d) Clozapine



Clozapine: Clozapine is superior to antipsychotics as compared to other antipsychotics in managing 'Treatment Resistant'. Schizophrenia. ('Treatment Resistant' Schizophrenia: Schizophrenia that has not responded to at least 2 different antipsychotics given at an adequate dosage for an adequate period of time i.e at least 4-6weeks each.).




 About 20% - 30% of patients with Schizophrenia are Treatment Resistant. The most important thing to keep in mind is Clozapine has also an antisuicidal effect.



General Principles Of Using Antipsychotics:

   "Start Low, Go Slow"
  • Start at a low dose 

  • If needed, increase the dose gradually

  • Review mental state regularly

  • Monitor for side-effects

  • Avoid antipsychotics 'polypharmacy'(using more than one at the same time).

General Principles When Using Antipsychotics:


  • It usually takes at least 2 to 3 weeks for the antipsychotic effect to manifest, and a further 2 to 3 weeks for it to maximize.

  • If the patient improves, do continue medication for several months after recovery.

  •  If the patient does not improve, change to another antipsychotic.

Long-Term Maintenance Treatment for Schizophrenia:


Maintenance treatment is given to:
  • Maintenance control over symptoms.

  • Reduce the risk of relapse.

  • Improve the quality of life/functioning.

How long it needs to be given depends on:

  • A number of episodes.

  • The severity of the episodes.

  • Impact of episodes on functioning.


Other treatment options for Schizophrenia:
  • Psychoeducation

  • Cognitive Behaviour Therapy (CBT)

  • Family Therapy 

  • Art Therapy

  • Cognitive Remediation Therapy

  • Social Skills Training.






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