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Medication is the best way to treat schizophrenia. Discuss this statement.

Introduction

In the early 1950s, Chlorpromazine first became available as a treatment for schizophrenia (Delay and Deniker) and it seemed that schizophrenia would be banished to textbooks
The introduction of the first antipsychotics appeared to support the idea that schizophrenia was an illness rather than a mere aberration of character, or due to faulty parenting. Earlier ideas of Fromm-Reichmann (schizophrenogenic mothers) and Bateson (Double-binds) have arguably done much damage to parents who for many years have blamed themselves for their children's illness
With the advent of genetic research and advanced scanning techniques, we are more clear now about the mechanisms at fault within the brains of those with schizophrenia
Perhaps with this renaissance of biological psychiatry, one would think that modern psychiatry would have new wonderdrugs with which to treat the illness which has always had such an intimate relationship with psychiatry for the last 100 years
In this essay, we will look firstly at psychotropic medication, its method of action, and its role in the treatment of schizophrenia. We will then examine other tools within the arsenal of psychiatrists in treating schizophrenia. Many of these are what could be called psychotherapies, and perhaps we have almost gone full circle in how we look at and treat schizophrenia.

Phenothiazines: a ray of hope

When the first papers came out in 1952 announcing a new and effective way of treating schizophrenia, it heralded a new optimism in the therapeutic management of schizophrenia
the first drugs (and many current drugs) were dopamine receptor antagonists, and this fact spurred on research and gave birth to the theory which has dominated schizophrenia for the last half-century - the dopaminergic hypothesis
this theory posited that the cause of schizophrenic symptoms was a general excess of dopamine in certain parts of the brain, and by blocking dopamine receptors, one could compensate for this dopaminergic excess and hence treat the symptoms
most drugs still in use have as part of their pharmacodynamic actions, antagonism of dopamine receptors, and more specifically, D2 receptors. The newer so-called 'atypical' drugs are still active at dopamine receptors, but have greater activity at serotonin (5-HT) receptors
it is probable that dopamine is involved in the symptomatology of schizophrenia, but like the human brain, it is evidently not that simple. Modern research is now looking at other transmitter systems, including GABA, glutamate, and acetylcholine, as well as the complex interaction between different systems

The antipsychotics: mainstay of treatment

antipsychotics, have been extensively researched, and it is pretty incontrovertible that in the acute phase, antipsychotics reduce symptoms, and in the longer term they can reduce the risk of relapse especially if used in longer-lasting depot preparations
they do have their problems however, and it can be argued that they present a far too simplistic view of such a complex illness. Side effects are common, they can be severe, and there are longer term risks of blood dyscrasias and untreatable movement disorders
medication has been with us for the last 50 years, and it will probably still be being used effectively in the next 50 years. But are there alternatives to drugs, do they work, and how can the two be combined most effectively to reduce symptoms, and improve the functioning of those with schizophrenia?

The Psychotherapies

there are many types of non-drug therapy out there, and more and more of them are being used in conjunction with medication to improve outcome
the evidence base for these therapies is also increasing, and many have been shown to improve numerous aspects of the illness
we will look at some of the more common, and the most studied non-pharmacological interventions in turn...

Cognitive-behavioural therapy for treatment-resistant positive symptoms

theorists and researchers have become increasingly interested in the cognitive processes that may be active or disturbed in psychosis. It is likely that there is no single process, but rather a combination of many different aspects of cognition including:
a negative appraisal of psychotic symptoms which results in emotional disturbance such as depression, anxiety, and low self-esteem
Anomalies of perception and experience of self result in aberrant appraisals and judgements which lead to unusual beliefs. For example, in an effort to explain hallucinatory voices, the individual may believe that an outside agency is attempting to communicate with them by unknown means.
CBT in the treatment of schizophrenia tends to draw on the cognitive therapy of Beck et al. (1979) in terms of principles and practice
there are three broad aims:

to reduce the distress and disability caused by psychotic symptoms
to reduce emotional disturbance
to help the individual arrive at an understanding of psychosis that promotes his participation in reducing the risk of relapse and levels of social disability

most of the principles are shared with CBT for depression, but others are geared more towards delusions, hallucinations, and managing relapse risk and social disability.
key steps in helping a patient reevaluate his beliefs about his internal experiences is to construct a new model of events that is acceptable and believable to the individual
a number of fairly small studies (Kuipers, Tarrier, Chadwick) have reported significant positive effect for CBT, but clearly more research is required to evaluate the role of CBT in the treatment of schizophrenia

Psychosocial skills training

skills training methods have developed over the last 20-30 years to address the social impairments associated with many cases of schizophrenia
less than 1 in 5 with schizophrenia are in full-time employment, and many are clearly socially and functionally impaired
the Patient Outcomes Research Team (PORT) study of 1995 (Scott and Dixon) conducted an independent literature review and concluded that social skills training should be included in the schizophrenia treatment arsenal
a number of other analyses of the literature have come to similar conclusions, and they suggest that:
patients with schizophrenia can be taught a wide range of social skills such as gazing and reciprocity during conversation, to more complex behaviours such as assertiveness and conversational skills
social skills training has a positive effect on patient's perceptions of themselves as more assertive and less anxious, but only moderate impact on psychiatric symptoms, relapse, and hospitalization
the training tends to only generalize to settings similar to training situations, with less effect in novel environments
long-term treatment outcome has yet to be evaluated

Family interventions

hopefully, the days when family members were blamed for their relative's illness are long gone, but perhaps the role of the family in treating the illness is now being recognized and utilized
in 1976, Vaughn and Leff published their highly influential study of the effects of 'expressed emotion' on relapse rates of schizophrenia. They found that patients who lived with families who scored highly in terms of hostility, critical comments, and over-involvement were more likely to relapse
more recently, the PORT investigators (Dixon and Lehman, 1995) recommended that patients who have ongoing contact with their families should be offered a family psychosocial intervention that combined a number of different elements such as:
education about illness
family support
crisis intervention
problem-solving skills training
they also suggested that the intervention should not be just restricted to those families with high levels of expressed emotion
a number of studies throughout the 1990s reported beneficial effects from family interventions on the relapse rates of schizophrenic relatives. Many have also reported less social dysfunction, longer employment, and lower levels of burden as judged by the families

Conclusions

unfortunately, schizophrenia is still with us, but hopefully with continuing research into both pharmacological and psychotherapeutic interventions, the disability associated with this condition can be lessened
we have seen that there are many approaches to reducing the dysfunction associated with schizophrenia, and many of these seem to share similar characteristics and treatment aims
probably the most likely long-term effect is that schizophrenia will be treated with a combination of antipsychotic medication and a variety of psychosocial interventions targeted at supporting families, and improving the social functioning of those with schizophrenia.