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. 1998 Apr-Jun;40(2):120–134.

MANAGEMENT OF SCHIZOPHRENIA : AN UPDATE

Parmanand Kulhara 1,✉
PMCID: PMC2965836  PMID: 21494460

Abstract

Introduction of potent antipsychotics for the treatment of schizophrenia not only brought changes in the outlook for management of this disorder but also infused optimism and hope. However, substantial number of patients fail to respond to conventional antipsychotics thus creating a class of patients who are termed as treatment resistant, treatment refractory or difficult to treat patients. This update focuses on such patients and provides description of various options for their management Though atypical antipsychotics offer respite to a vast number of such difficult to treat patients, their efficacy is perhaps over-emphasised. Conversely, the potential of psychosocial therapies in such patients has not been fully exploited. Management of such patients in the community is a challenge and in taking up this gauntlet, a judicious mix of pharmacotherapy and psychosocial intervention strategies, close monitoring of the patients with a view to detect prodromes of relapse and early intervention are likely to play increasingly important part.

Keywords: Schizophrenia, management, psycho-social, psychophanvacology

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Selected References

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  1. Atkin K., Veys P. Clozapine-induced neutropenia, or not. Br J Psychiatry. 1994 Sep;165(3):407–408. doi: 10.1192/bjp.165.3.407b. [DOI] [PubMed] [Google Scholar]
  2. Breier A., Buchanan R. W., Kirkpatrick B., Davis O. R., Irish D., Summerfelt A., Carpenter W. T., Jr Effects of clozapine on positive and negative symptoms in outpatients with schizophrenia. Am J Psychiatry. 1994 Jan;151(1):20–26. doi: 10.1176/ajp.151.1.20. [DOI] [PubMed] [Google Scholar]
  3. Chadwick P. D., Lowe C. F. Measurement and modification of delusional beliefs. J Consult Clin Psychol. 1990 Apr;58(2):225–232. doi: 10.1037//0022-006x.58.2.225. [DOI] [PubMed] [Google Scholar]
  4. Chadwick P., Birchwood M. The omnipotence of voices. A cognitive approach to auditory hallucinations. Br J Psychiatry. 1994 Feb;164(2):190–201. doi: 10.1192/bjp.164.2.190. [DOI] [PubMed] [Google Scholar]
  5. Chouinard G., Jones B., Remington G., Bloom D., Addington D., MacEwan G. W., Labelle A., Beauclair L., Arnott W. A Canadian multicenter placebo-controlled study of fixed doses of risperidone and haloperidol in the treatment of chronic schizophrenic patients. J Clin Psychopharmacol. 1993 Feb;13(1):25–40. [PubMed] [Google Scholar]
  6. Ciompi L. The natural history of schizophrenia in the long term. Br J Psychiatry. 1980 May;136:413–420. doi: 10.1192/bjp.136.5.413. [DOI] [PubMed] [Google Scholar]
  7. Das M. K., Kulhara P. L., Verma S. K. Life events preceding relapse of schizophrenia. Int J Soc Psychiatry. 1997 Spring;43(1):56–63. doi: 10.1177/002076409704300105. [DOI] [PubMed] [Google Scholar]
  8. DeLisi L. E., Hoff A. L., Kushner M., Calev A., Stritzke P. Left ventricular enlargement associated with diagnostic outcome of schizophreniform disorder. Biol Psychiatry. 1992 Jul 15;32(2):199–201. doi: 10.1016/0006-3223(92)90025-u. [DOI] [PubMed] [Google Scholar]
  9. Dixon L. B., Lehman A. F. Family interventions for schizophrenia. Schizophr Bull. 1995;21(4):631–643. doi: 10.1093/schbul/21.4.631. [DOI] [PubMed] [Google Scholar]
  10. Drake R. E., McLaughlin P., Pepper B., Minkoff K. Dual diagnosis of major mental illness and substance disorder: an overview. New Dir Ment Health Serv. 1991 Summer;(50):3–12. doi: 10.1002/yd.23319915003. [DOI] [PubMed] [Google Scholar]
  11. Essock S. M., Hargreaves W. A., Dohm F. A., Goethe J., Carver L., Hipshman L. Clozapine eligibility among state hospital patients. Schizophr Bull. 1996;22(1):15–25. doi: 10.1093/schbul/22.1.15. [DOI] [PubMed] [Google Scholar]
  12. Falloon I. R., Boyd J. L., McGill C. W., Razani J., Moss H. B., Gilderman A. M. Family management in the prevention of exacerbations of schizophrenia: a controlled study. N Engl J Med. 1982 Jun 17;306(24):1437–1440. doi: 10.1056/NEJM198206173062401. [DOI] [PubMed] [Google Scholar]
  13. Falloon I. R., Boyd J. L., McGill C. W., Williamson M., Razani J., Moss H. B., Gilderman A. M., Simpson G. M. Family management in the prevention of morbidity of schizophrenia. Clinical outcome of a two-year longitudinal study. Arch Gen Psychiatry. 1985 Sep;42(9):887–896. doi: 10.1001/archpsyc.1985.01790320059008. [DOI] [PubMed] [Google Scholar]
  14. Falloon I. R., Shanahan W. J. Community management of schizophrenia. Br J Hosp Med. 1990 Jan;43(1):62–66. [PubMed] [Google Scholar]
  15. Farmer A. E., Blewett A. Drug treatment of resistant schizophrenia. Limitations and recommendations. Drugs. 1993 Mar;45(3):374–383. doi: 10.2165/00003495-199345030-00006. [DOI] [PubMed] [Google Scholar]
  16. Garety P., Fowler D., Kuipers E., Freeman D., Dunn G., Bebbington P., Hadley C., Jones S. London-East Anglia randomised controlled trial of cognitive-behavioural therapy for psychosis. II: Predictors of outcome. Br J Psychiatry. 1997 Nov;171:420–426. doi: 10.1192/bjp.171.5.420. [DOI] [PubMed] [Google Scholar]
  17. Hogarty G. E., Anderson C. M., Reiss D. J., Kornblith S. J., Greenwald D. P., Javna C. D., Madonia M. J. Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare treatment of schizophrenia. I. One-year effects of a controlled study on relapse and expressed emotion. Arch Gen Psychiatry. 1986 Jul;43(7):633–642. doi: 10.1001/archpsyc.1986.01800070019003. [DOI] [PubMed] [Google Scholar]
  18. Hogarty G. E., Kornblith S. J., Greenwald D., DiBarry A. L., Cooley S., Flesher S., Reiss D., Carter M., Ulrich R. Personal therapy: a disorder-relevant psychotherapy for schizophrenia. Schizophr Bull. 1995;21(3):379–393. doi: 10.1093/schbul/21.3.379. [DOI] [PubMed] [Google Scholar]
  19. Hogarty G. E., McEvoy J. P., Munetz M., DiBarry A. L., Bartone P., Cather R., Cooley S. J., Ulrich R. F., Carter M., Madonia M. J. Dose of fluphenazine, familial expressed emotion, and outcome in schizophrenia. Results of a two-year controlled study. Arch Gen Psychiatry. 1988 Sep;45(9):797–805. doi: 10.1001/archpsyc.1988.01800330021002. [DOI] [PubMed] [Google Scholar]
  20. Jeste D. V., Caligiuri M. P. Tardive dyskinesia. Schizophr Bull. 1993;19(2):303–315. doi: 10.1093/schbul/19.2.303. [DOI] [PubMed] [Google Scholar]
  21. Kane J. M. Clinical efficacy of clozapine in treatment-refractory schizophrenia: an overview. Br J Psychiatry Suppl. 1992 May;(17):41–45. [PubMed] [Google Scholar]
  22. Kane J. M. Compliance issues in outpatient treatment. J Clin Psychopharmacol. 1985 Jun;5(3 Suppl):22S–27S. doi: 10.1097/00004714-198506001-00005. [DOI] [PubMed] [Google Scholar]
  23. Kane J. M., McGlashan T. H. Treatment of schizophrenia. Lancet. 1995 Sep 23;346(8978):820–825. doi: 10.1016/s0140-6736(95)91630-x. [DOI] [PubMed] [Google Scholar]
  24. Kane J., Honigfeld G., Singer J., Meltzer H. Clozapine for the treatment-resistant schizophrenic. A double-blind comparison with chlorpromazine. Arch Gen Psychiatry. 1988 Sep;45(9):789–796. doi: 10.1001/archpsyc.1988.01800330013001. [DOI] [PubMed] [Google Scholar]
  25. Kemp R., Hayward P., Applewhaite G., Everitt B., David A. Compliance therapy in psychotic patients: randomised controlled trial. BMJ. 1996 Feb 10;312(7027):345–349. doi: 10.1136/bmj.312.7027.345. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Kingdon D. G., Turkington D. The use of cognitive behavior therapy with a normalizing rationale in schizophrenia. Preliminary report. J Nerv Ment Dis. 1991 Apr;179(4):207–211. doi: 10.1097/00005053-199104000-00005. [DOI] [PubMed] [Google Scholar]
  27. Kingdon D., Turkington D., John C. Cognitive behaviour therapy of schizophrenia. The amenability of delusions and hallucinations to reasoning. Br J Psychiatry. 1994 May;164(5):581–587. doi: 10.1192/bjp.164.5.581. [DOI] [PubMed] [Google Scholar]
  28. Kuipers E., Garety P., Fowler D., Dunn G., Bebbington P., Freeman D., Hadley C. London-East Anglia randomised controlled trial of cognitive-behavioural therapy for psychosis. I: effects of the treatment phase. Br J Psychiatry. 1997 Oct;171:319–327. doi: 10.1192/bjp.171.4.319. [DOI] [PubMed] [Google Scholar]
  29. Kuipers E. The management of difficult to treat patients with schizophrenia, using non-drug therapies. Br J Psychiatry Suppl. 1996 Dec;(31):41–51. [PubMed] [Google Scholar]
  30. Leff J., Berkowitz R., Shavit N., Strachan A., Glass I., Vaughn C. A trial of family therapy v. a relatives group for schizophrenia. Br J Psychiatry. 1989 Jan;154:58–66. doi: 10.1192/bjp.154.1.58. [DOI] [PubMed] [Google Scholar]
  31. Leff J., Berkowitz R., Shavit N., Strachan A., Glass I., Vaughn C. A trial of family therapy versus a relatives' group for schizophrenia. Two-year follow-up. Br J Psychiatry. 1990 Oct;157:571–577. doi: 10.1192/bjp.157.4.571. [DOI] [PubMed] [Google Scholar]
  32. Lieberman J. A., Jody D., Alvir J. M., Ashtari M., Levy D. L., Bogerts B., Degreef G., Mayerhoff D. I., Cooper T. Brain morphology, dopamine, and eye-tracking abnormalities in first-episode schizophrenia. Prevalence and clinical correlates. Arch Gen Psychiatry. 1993 May;50(5):357–368. doi: 10.1001/archpsyc.1993.01820170035005. [DOI] [PubMed] [Google Scholar]
  33. Lieberman J., Bogerts B., Degreef G., Ashtari M., Lantos G., Alvir J. Qualitative assessment of brain morphology in acute and chronic schizophrenia. Am J Psychiatry. 1992 Jun;149(6):784–794. doi: 10.1176/ajp.149.6.784. [DOI] [PubMed] [Google Scholar]
  34. Lieberman J., Jody D., Geisler S., Alvir J., Loebel A., Szymanski S., Woerner M., Borenstein M. Time course and biologic correlates of treatment response in first-episode schizophrenia. Arch Gen Psychiatry. 1993 May;50(5):369–376. doi: 10.1001/archpsyc.1993.01820170047006. [DOI] [PubMed] [Google Scholar]
  35. Lindström L. H. The effect of long-term treatment with clozapine in schizophrenia: a retrospective study in 96 patients treated with clozapine for up to 13 years. Acta Psychiatr Scand. 1988 May;77(5):524–529. doi: 10.1111/j.1600-0447.1988.tb05164.x. [DOI] [PubMed] [Google Scholar]
  36. Macpherson R., Jerrom B., Hughes A. A controlled study of education about drug treatment in schizophrenia. Br J Psychiatry. 1996 Jun;168(6):709–717. doi: 10.1192/bjp.168.6.709. [DOI] [PubMed] [Google Scholar]
  37. Marder S. R., Van Putten T. Who should receive clozapine? Arch Gen Psychiatry. 1988 Sep;45(9):865–867. doi: 10.1001/archpsyc.1988.01800330099012. [DOI] [PubMed] [Google Scholar]
  38. Mari J. J., Streiner D. L. An overview of family interventions and relapse on schizophrenia: meta-analysis of research findings. Psychol Med. 1994 Aug;24(3):565–578. doi: 10.1017/s0033291700027720. [DOI] [PubMed] [Google Scholar]
  39. Marks I. M., Connolly J., Muijen M., Audini B., McNamee G., Lawrence R. E. Home-based versus hospital-based care for people with serious mental illness. Br J Psychiatry. 1994 Aug;165(2):179–194. doi: 10.1192/bjp.165.2.179. [DOI] [PubMed] [Google Scholar]
  40. McEvoy J. P., Hogarty G. E., Steingard S. Optimal dose of neuroleptic in acute schizophrenia. A controlled study of the neuroleptic threshold and higher haloperidol dose. Arch Gen Psychiatry. 1991 Aug;48(8):739–745. doi: 10.1001/archpsyc.1991.01810320063009. [DOI] [PubMed] [Google Scholar]
  41. McFarlane W. R., Lukens E., Link B., Dushay R., Deakins S. A., Newmark M., Dunne E. J., Horen B., Toran J. Multiple-family groups and psychoeducation in the treatment of schizophrenia. Arch Gen Psychiatry. 1995 Aug;52(8):679–687. doi: 10.1001/archpsyc.1995.03950200069016. [DOI] [PubMed] [Google Scholar]
  42. Meltzer H. Y., Burnett S., Bastani B., Ramirez L. F. Effects of six months of clozapine treatment on the quality of life of chronic schizophrenic patients. Hosp Community Psychiatry. 1990 Aug;41(8):892–897. doi: 10.1176/ps.41.8.892. [DOI] [PubMed] [Google Scholar]
  43. Meltzer H. Y. Treatment of the neuroleptic-nonresponsive schizophrenic patient. Schizophr Bull. 1992;18(3):515–542. doi: 10.1093/schbul/18.3.515. [DOI] [PubMed] [Google Scholar]
  44. Muijen M., Marks I. M., Connolly J., Audini B., McNamee G. The daily living programme. Preliminary comparison of community versus hospital-based treatment for the seriously mentally ill facing emergency admission. Br J Psychiatry. 1992 Mar;160:379–384. doi: 10.1192/bjp.160.3.379. [DOI] [PubMed] [Google Scholar]
  45. Nelson H. E., Thrasher S., Barnes T. R. Practical ways of alleviating auditory hallucinations. BMJ. 1991 Feb 9;302(6772):327–327. doi: 10.1136/bmj.302.6772.327. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Penn D. L., Mueser K. T. Research update on the psychosocial treatment of schizophrenia. Am J Psychiatry. 1996 May;153(5):607–617. doi: 10.1176/ajp.153.5.607. [DOI] [PubMed] [Google Scholar]
  47. Persaud R., Marks I. A pilot study of exposure control of chronic auditory hallucinations in schizophrenia. Br J Psychiatry. 1995 Jul;167(1):45–50. doi: 10.1192/bjp.167.1.45. [DOI] [PubMed] [Google Scholar]
  48. Pickar D., Owen R. R., Litman R. E., Konicki E., Gutierrez R., Rapaport M. H. Clinical and biologic response to clozapine in patients with schizophrenia. Crossover comparison with fluphenazine. Arch Gen Psychiatry. 1992 May;49(5):345–353. doi: 10.1001/archpsyc.1992.01820050009001. [DOI] [PubMed] [Google Scholar]
  49. Razali M. S., Yahya H. Compliance with treatment in schizophrenia: a drug intervention program in a developing country. Acta Psychiatr Scand. 1995 May;91(5):331–335. doi: 10.1111/j.1600-0447.1995.tb09790.x. [DOI] [PubMed] [Google Scholar]
  50. Regier D. A., Farmer M. E., Rae D. S., Locke B. Z., Keith S. J., Judd L. L., Goodwin F. K. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA. 1990 Nov 21;264(19):2511–2518. [PubMed] [Google Scholar]
  51. Rifkin A., Doddi S., Karajgi B., Borenstein M., Wachspress M. Dosage of haloperidol for schizophrenia. Arch Gen Psychiatry. 1991 Feb;48(2):166–170. doi: 10.1001/archpsyc.1991.01810260074011. [DOI] [PubMed] [Google Scholar]
  52. SHAPIRO M. B., RAVENETTE A. T. A preliminary experiment on paranoid delusions. J Ment Sci. 1959 Apr;105(439):295–312. doi: 10.1192/bjp.105.439.295. [DOI] [PubMed] [Google Scholar]
  53. Schooler N. R. Integration of family and drug treatment strategies in the treatment of schizophrenia: a selective review. Int Clin Psychopharmacol. 1995 Sep;10 (Suppl 3):73–80. [PubMed] [Google Scholar]
  54. Shaner A., Khalsa M. E., Roberts L., Wilkins J., Anglin D., Hsieh S. C. Unrecognized cocaine use among schizophrenic patients. Am J Psychiatry. 1993 May;150(5):758–762. doi: 10.1176/ajp.150.5.758. [DOI] [PubMed] [Google Scholar]
  55. Tarrier N., Barrowclough C., Porceddu K., Fitzpatrick E. The Salford Family Intervention Project: relapse rates of schizophrenia at five and eight years. Br J Psychiatry. 1994 Dec;165(6):829–832. doi: 10.1192/bjp.165.6.829. [DOI] [PubMed] [Google Scholar]
  56. Tarrier N., Barrowclough C., Vaughn C., Bamrah J. S., Porceddu K., Watts S., Freeman H. Community management of schizophrenia. A two-year follow-up of a behavioural intervention with families. Br J Psychiatry. 1989 May;154:625–628. doi: 10.1192/bjp.154.5.625. [DOI] [PubMed] [Google Scholar]
  57. Tarrier N., Barrowclough C., Vaughn C., Bamrah J. S., Porceddu K., Watts S., Freeman H. The community management of schizophrenia. A controlled trial of a behavioural intervention with families to reduce relapse. Br J Psychiatry. 1988 Oct;153:532–542. doi: 10.1192/bjp.153.4.532. [DOI] [PubMed] [Google Scholar]
  58. Tarrier N., Lowson K., Barrowclough C. Some aspects of family interventions in schizophrenia. II: Financial considerations. Br J Psychiatry. 1991 Oct;159:481–484. doi: 10.1192/bjp.159.4.481. [DOI] [PubMed] [Google Scholar]
  59. Telles C., Karno M., Mintz J., Paz G., Arias M., Tucker D., Lopez S. Immigrant families coping with schizophrenia. Behavioral family intervention v. case management with a low-income Spanish-speaking population. Br J Psychiatry. 1995 Oct;167(4):473–479. doi: 10.1192/bjp.167.4.473. [DOI] [PubMed] [Google Scholar]
  60. Terkelsen K. G., Grosser R. C. Estimating clozapine's cost to the nation. Hosp Community Psychiatry. 1990 Aug;41(8):863–869. doi: 10.1176/ps.41.8.863. [DOI] [PubMed] [Google Scholar]
  61. Van Putten T., Marder S. R., Mintz J. A controlled dose comparison of haloperidol in newly admitted schizophrenic patients. Arch Gen Psychiatry. 1990 Aug;47(8):754–758. doi: 10.1001/archpsyc.1990.01810200062009. [DOI] [PubMed] [Google Scholar]
  62. Van Putten T., Marshall B. D., Liberman R., Mintz J., Kuehnel T. G., Bowen L., Aravagiri M., Marder S. R. Systematic dosage reduction in treatment-resistant schizophrenic patients. Psychopharmacol Bull. 1993;29(2):315–320. [PubMed] [Google Scholar]
  63. Vaughn C. E., Leff J. P. Patterns of emotional response in relatives of schizophrenic patients. Schizophr Bull. 1981;7(1):43–44. doi: 10.1093/schbul/7.1.43. [DOI] [PubMed] [Google Scholar]
  64. Vaughn C. E., Leff J. P. The influence of family and social factors on the course of psychiatric illness. A comparison of schizophrenic and depressed neurotic patients. Br J Psychiatry. 1976 Aug;129:125–137. doi: 10.1192/bjp.129.2.125. [DOI] [PubMed] [Google Scholar]
  65. Watts F. N., Powell G. E., Austin S. V. The modification of abnormal beliefs. Br J Med Psychol. 1973 Dec;46(4):359–363. doi: 10.1111/j.2044-8341.1973.tb02260.x. [DOI] [PubMed] [Google Scholar]
  66. Weinberger D. R., Cannon-Spoor E., Potkin S. G., Wyatt R. J. Poor premorbid adjustment and CT scan abnormalities in chronic schizophrenia. Am J Psychiatry. 1980 Nov;137(11):1410–1413. doi: 10.1176/ajp.137.11.1410. [DOI] [PubMed] [Google Scholar]
  67. Wykes T. Predicting symptomatic and behavioural outcomes of community care. Br J Psychiatry. 1994 Oct;165(4):486–492. doi: 10.1192/bjp.165.4.486. [DOI] [PubMed] [Google Scholar]
  68. Yesavage J. A., Zarcone V. History of drug abuse and dangerous behavior in inpatient schizophrenics. J Clin Psychiatry. 1983 Jul;44(7):259–261. [PubMed] [Google Scholar]

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