Schizophrenia Treatment Should Focus On Recovery, Not Just Symptoms
Psychiatry has overemphasized pharmacotherapy of symptoms and underutilizedproven psychosocial treatments, while paying little attentionto the substantial medical complications confronting patientswith schizophrenia, says one expert.
Functional outcome, not merely symptom relief, should be theclinical focus in the treatment of schizophrenia, said StephenMarder, M.D., in an address titled "Recovery in Schizophrenia"at last month's Institute on Psychiatric Services in Atlanta.
Marder called for a new focus by psychiatrists on the physicalhealth of patients with schizophrenia and incorporation of thebroad range of proven psychosocial treatments. He also calledfor a new research agenda aimed at developing drugs to treatcognitive deficits—the feature of schizophrenia most stronglyassociated with functional outcome .
The sum of those recommendations is a new orientation towardrecovery, which Marder described as a process—not an end-point—inwhich a patient can engage throughout the stages of illnesseven as he or she retains some symptoms.
This orientation marks a fairly major departure from standardpsychiatric care, which Marder said has overemphasized pharmacotherapyof positive symptoms and underutilized proven psychosocial treatments,while all but ignoring the substantial medical complicationsconfronting patients with schizophrenia.
"We need to have a paradigm of treatment that focuses on functional outcomeas the most important outcome, with symptoms as things to beconcerned about," Marder said. "We need to use both psychosocialand pharmacologic treatments. And I believe that psychiatristsand mental health care providers need to take more responsibilityfor the physical health of our patients, a serious problem thatup until now has not been adequately addressed."
Marder is director of the section on psychosis of the UCLA Neuropsychiatric Instituteand a professor of psychiatry at the David Geffen School ofMedicine at UCLA.
For five decades, treatment of people with schizophrenia haslargely relied on pharmacotherapy, and while those drugs haverelieved much suffering, functional outcomes are not much improvedfrom the point when antipsychotics were first introduced, Mardersaid.
"If a goal is [getting patients back to] work, only about 20percent of patients with schizophrenia are currently working,"Marder said. "And clinical practice, as it is engaged in clinicsand hospitals, is largely focused on symptoms."
Marder emphasized that better treatment of cognitive deficits—not merelyamelioration of symptoms—is the key to improving functional outcomesin people with schizophrenia.
"Symptoms can be handicaps on the way to recovery, but peoplecan recover who have symptoms," he said. “People can work who experiencehallucinations and have suspicious thoughts, just as peoplecan recover and prosper if they are missing a limb. It's a handicap,not the endpoint of treatment.
"Patients need to be at the center and be active partners insetting goals of treatment," he said. "But one of the obstaclesis American psychiatry. Our focus on symptoms and away fromthe functional recovery that patients are asking for is whythere is this controversy. Patients and families are askingfor a recovery model, and we need to respond."
Marder outlined the psychosocial treatments that have a literatureof efficacy behind them when combined with antipsychotic medication.These include illness education, family interventions, supportedemployment, assertive community treatment, skills training,and cognitive-behavioral therapy.
He emphasized that evolving research on psychosocial therapieshas shown that they act on different aspects of the patient'sillness than do medications. For instance, he described studiesshowing that skills training had no impact on relapse, but hada profound effect on social outcome and patient quality of life.
He also stressed that the effects of psychosocial treatmentare generally not seen in the short term. "Psychiatrists underestimatethe effectiveness of these treatments because patients don'treceive them long enough," Marder said.
He especially highlighted the importance of supported employment."No treatment I have seen is as effective as a part-time job,"Marder said. "Nothing contributes as much to self-esteem andcommunity integration than being able to interact with co-workerson a regular basis, and there is nothing more reinforcing toa patient than being given a positive review by a supervisorand being paid for one's work."
Marder said a most urgent change necessary in the treatmentof schizophrenia is a new attention on the part of mental healthprofessionals to the medical complications typically seen inthe disease.
Patients with schizophrenia have a high smoking rate and areat higher risk for obesity, diabetes, and hypertension. He saidthe average lifespan for a patient with schizophrenia is 15years less than the general population. "The increased riskfor suicide has little to do with it," he said. "Our patientsare dying of heart disease."
Marder described a conference on the subject in late 2002 atMount Sinai University School of Medicine in New York that broughttogether a host of experts on schizophrenia, diabetes, heartdisease, and preventative health, among other topics.
Consensus recommendations developed at the conference calledfor regular monitoring of body mass index, plasma glucose level,lipid profiles, and signs of prolactin elevation or sexual dysfunction—allof which should guide the selection of antipsychotic agents(Psychiatric News, March 5, September 17).
Specific recommendations were made for cardiac monitoring ofpatients who receive medications associated with QT intervalprolongation and for monitoring for signs of myocarditis inpatients treated with clozapine. Patients who receive both first-and second-generation antipsychotic medications should be examinedfor extrapyramidal symptoms and tardive dyskinesia. Patientswith schizophrenia should also receive regular visual examinations,according to the recommendations. These recommendations appeared in"Physical Health Monitoring of Patients With Schizophrenia"in the August American Journal of Psychiatry.
"Implementing these recommendations in a psychiatric settingisn't going to be easy, but it is self-evident that it shouldbe happening," Marder said. "The treating psychiatrist may notbe able to manage many of these medical problems, but they needto be certain that someone does."