Transcript Current research and practice in the treatment of schizophrenia

Current research and
practice in the treatment of
schizophrenia
Dr. Aaron Frost
What is Schizophrenia
Dementia Praecox
“Split Mind”
Psychotic illness (out of touch with reality)
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Hallucinations & Delusions (Bizarre or not)
Negative Symptoms
Apathy, Avolition, Alogia
Disorganisation (thought disorder)
Catatonia
Subtypes
Catatonic
Disorganised
Paranoid
Undifferentiated
Residual
Facts and Figures
Life time prevalence of just under 1 per
hundred
Yearly incidence averages out to 15:100,000
Modal age of onset
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Men : 18 – 25
Women : 25 – 35 (second peak after
menopause)
Early Onset linked with poor prognosis
Cost of Schizophrenia
$46,200 per patient per year
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$27,500 lost productivity
$13,800 in patient treatment
$4,900 in other community care
$1.45 billion direct costs
$2.25 billion societal costs.
Carr et al., (2003)
Averting Burden
Current
Optimal
Unavertable
Current treatment of
schizophrenia can
avert approximately
13% of the burden
Optimal treatment
could avert 22% of
the burden
The majority of the
burden of
schizophrenia cannot
currently be averted
Andrews et al., (2003)
What Causes Schizophrenia
50% Genetic concordance (polygenic)
Birth Complications
Late Winter / Spring births (vitamin D)
Bidirectional relationship with cannabis
Stress
Neurochemical
Neurobiological
Dopamine Hypothesis
Kapur et al., (1995)
Reduced Neuropil Hypothesis
Normal
Schizophrenia
Seleman et al., (1998)
Schizophrenia is degenerative
Thompson et al., (2001)
What works in Schizophrenia
Intervention
Medication
Family Therapy
CBT
Supported
Accommodation
Vocational
Rehabilitation
Assertive Case
Management
Level of
Evidence
I
I
Reference
I
III-c
Gould et al., (2001)
Girolamo et al., (2005)
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III-b
II
Twamley et al., (2003)
Warner (2002)
Rosen & Teesson
(2002)
Davis et al., (2003)
Pilling et al., (2002)
What doesn’t work in Schizophrenia
Intervention
Social Skills Training
Level of Reference
Evidence
I
Pilling et al., (2002)
Cognitive remediation
I
Pilling et al., (2002)
Case Management
I
Marhsall et al.,
(2001)
All medications are created equal
Neuroleptics
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Chlorpromazine
Haloperidol (plus a dozen others)
Atypical Antipsychotics
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Risperidone
Olanzapine
Quetiepine
Amisulpride
Aripiprazole
Side effect profile varies, efficacy does not
Except One
Clozapine is genuinely more effective than all
other agents (both statistically and clinically
significant)
Clozapine is also the only one with
demonstrated efficacy / effectiveness on
negative symptoms
Clozapine occasionally causes a fatal white
blood condition called agranulocytosis (1 – 2%
patients)
Cost of administration is very high
Alvir et al (2003)
Medication Compliance
Medication compliance is often poor and
intermittent
Partly this is due to lack of insight, partly
due to the severity of side effects
Long acting depot medications are
available for the neuroleptics, but currently
only one of the atypicals.
Efficacy of Treatment
Hegerty et al., (1994)
Why are we getting less effective ?
Health Data
Patient Functioning over Time
25
HoNOS
20
High
15
Middle
10
Low
5
0
intake
3mths
6mths
9mths
12mths
Early Intervention
Early Intervention has been proposed as
an approach to the treatment of
schizophrenia that has a more hopeful
prognosis
Pre-morbid
Prodrome
DUP
Psychosis
Prevention is difficult
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The best studies find around 30% transition
rate
Reduction in DUP is crucial
Psychological Interventions
Self Esteem
Family Therapy
Cognitive Therapy