Schizophrenia – pharmacological treatments, patient involvement and organization of care

The Swedish Council on Health Technology Assessment in Health Care (SBU) conducted a systematic literature review of research on effects of antipsychotics for treatment of schizophrenia, with a focus on second generation antipsychotics (SGA). The review also contains chapters on patient perspectives on treatment and integrated care for persons with mental illnesses with an emphasis on persons with schizophrenia.

Background

Schizophrenia is usually a chronic and disabling psychiatric disorder which afflicts approximately one per cent of the population world-wide with little gender differences.

First generation antipsychotic drugs (FGA) such as chlorpromazine and haloperidol have traditionally been used as first-line antipsychotics for people with schizophrenia.

Today SGA drugs such as olanzapine and risperidone are used more widely. The objective of this report was to compile the available scientific evidence on the efficacy and side effects of using SGA as first-line treatment. A second objective was to evaluate the scientific evidence for the psychiatric treatment process in terms of empowerment, from the patient perspective.

Method

A systematic review was undertaken following the PRISMA statement and standard methods used by SBU. A literature search was conducted in international medical data bases, with a last updated search May 2011. Studies that fulfilled the strict inclusion criteria were independently assessed for relevance and quality, using pre-set protocols, by two experts in the field. Discrepancies were resolved through discussion. The strength of the scientific evidence was assessed with the GRADE system.

Conclusions

Pharmacological treatments

• For people with schizophrenia better medical treatment can save lives. The SGA drugs clozapine, olanzapine and risperidone have better effects on psychotic symptoms than FGA drugs. Adverse effects differ between different the SGA drugs and are generally dose dependent. Pharmaceutical treatment options are generally cost effective, but there are few studies comparing the cost-effectiveness between individual SGA drugs.
• For people with treatment resistant schizo­phrenia, clozapine is the SGA drug with best effect on psychotic symptoms. Clozapine re­duces the risk for suicidal behavior and may, at the same time, reduce the risk for drug and alcohol abuse. However, approximately 1% of those being treated with clozapine develop agranulocytosis (a substantial decrease in white blood cells) which increases the risk of infection and can be life threatening. Clozapine and olanzapine can cause substantial weight gain, especially when the treatment is started for the first time. Those being treated with Risperdone run a higher risk of developing severe movement disorders such as extrapyramidal symp­toms and tardive dyskinesia, in comparison to those taking other SGA drugs.
• It is important that treatment plans address risk behaviours such as smoking, alcohol and drug abuse, low physical activity, and unbal­anced diet in persons with schizophrenia.
• It is estimated that a person with schizophrenia will live 20 years less than the general population, in part due to the increased rates for suicide, coronary diseases and lifestyle diseases.

Patient involvement and organization of care

• The scientific evidence supports the view that the perspectives and views of patients and those closest to them should be taken into consideration when psychiatric treatment is planned. It is important to not underestimate the opportunities that shared decision making may provide. Maintaining a good relation­ship, based on mutual respect, between patient and health care providers, is essential when caring for people with schizophrenia. People with schizophrenia also need their contact with their health care providers to be stable, and should be involved in the planning of their own care plan. Effective communication between all of those involved, including the patient, care givers, friends and family, is of great importance.
• Patients, as well as their friends and relatives, and health care professionals, agree that pharmacological treatment is necessary but incomplete. Having sound relationships between the person with schizophrenia and their friends, their family and their care givers is particularly important for recovery. Any support that helps these individuals build or maintain their social network is valuable. People with schizophrenia, and to some extent their families and friends, also need active help combating discrimination and social isolation.