Schizophrenia: Diagnosis, Treatment and Psychiatric Rehabilitation

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Schizophrenia Diagnosis, Treatment and
Psychiatric Rehabilitation

• Li-Shiun Chen, MD, MPH, ScD
• Department of Psychiatry
• Washington University
• April 12, 2008

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Schizophrenia

• Diagnosis
• Psychiatric Managment
• Psychosocial Rehabilitation
• Our Goals in Mental Health
• Conte Center Services

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The changed boy

• Mom We did not know what was going on, he just
  slowly changed to be more quiet, staying in his
  room all the time, not telling us what he is
  thinking, feeling not connected .
• Dad I tried to get him out, play sports or what,
  but he is not interested.
• Patient (does not want to talk, appears confused
  or upset or happy) I dont know.
• Sister Now she is scared of him, said mom.

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DSM IV Diagnostic Criteria

• Characteristic symptoms Two (or more) of the
  following, each present for a significant portion
  of time during a 1-month period (or less if
  successfully treated)
• delusions
• hallucinations
• disorganized speech (e.g., frequent derailment or
  incoherence)
• grossly disorganized or catatonic behavior
• negative symptoms, i.e., affective flattening,
  alogia, or avolition
• Other consideration Duration, Impairment,
  Exclusion

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Diagnostic Assessment

• Differential Diagnoses
• Physical and Laboratory Assessment per APA
  Practice Guidelines
• Vital Signs
• BMI
• CBC, CMP, Thyroid, FBG, Lipids, other infection,
  ß-HCG, toxicology screen, EKG, Prolactin
• imaging
• Neurological exam (EPS, TD)
• Eye exam (Cataracts)

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Psychiatric Management

• Assess symptoms and establish a diagnosis
• Formulate and implement a treatment plan
• Therapeutic alliance/treatment adherence
• Provide patient/family education and therapies
• Treat comorbid conditions (major depression,
  substance use disorders, PTSD)
• Psychosocial rehabilitation (assess functioning)
• Coordinate with other specialty clinicians
• Phase specific management

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Acute Phase

• Prevent harm
• Reduce symptoms
• Antipsychotic Medication
• Choice of medication (Risk Benefits Side Effects)
• Use of adjunctive medication
• Use of other somatic therapies (ECT)

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Special Issues after 1st Episode

• Carefully observe ? differential diagnoses,
  comorbidity
• Natural course (70 achieve full remission within
  3-4 months, 80 achieve stable remission within 1
  year)
• Strive to minimize risk of relapse
• Aim to eliminate exposure to cannabinoids and
  psychostimulants, enhance stress management,
  employ maintenance antipsychotic treatment
• Discuss prudent treatment options

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Stablization Phase

• Minimize the likelihood of relapse
• Enhance adaptation
• Facilitate continued reduction in symptoms and
  promote the process of recovery

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Stable Phase

• Ensure symptom remission or control
• Maintain/improve level of functioning and quality
  of life
• Effectively treat increases in symptoms or
  relapses (antipsychotics can reduce risk of
  relapse to less than 30 per year)
• Monitor adverse treatment effects

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Multidisciplinary Teamwork in Psychiatric
Rehabilitation

• Goal of psychiatric rehabilitation
• Highest possible levels of social and vocational
  functioning and well-being for individuals with
  severe and persistent mental disorders
• Least interference from symptoms and
  neurocognitive impairments
• Psychiatric Rehabilitation is multidisciplinary,
  because of the many competencies required

Liberman 2001 Psych Services
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Available Evidence-based Treatments for
Rehabilitation
Kopelowics 2003 Psych Services
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Assessment from acute Exacerbation to Recovery
Kopelowics 2003 Psych Services
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Liberman 2001 Psych Services
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Psychosocial Treatment of Schizophrenia

• Evidence Review of randomized control trials of
  psychosocial interventions (year 1966-2000)
• Family Therapy
• Case Management/Assertive Community Training
• Social Skills Training
• Vocational Rehabilitation
• Cognitive Behavioral Therapy
• Individual Therapy

Bustillo 2001 AJP
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Lenroot R, 2003
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Medication Adherence in Schizophrenia

• Review of studies between 1800 and 2000
• Psychoeducation without accompanying behavioral
  components and supportive services are not likely
  to be effective
• What is effective?
• Assertive Community Treatment
• Motivational Interviewing
• Concrete instructions and problem-solving
  strategies

Zygmunt 2002 AJP
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Zygmunt 2002 AJP
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Assertive Community Treatment (ACT)

• ACT is effective
• Reducing hospitalization
• No more expensive than traditional care
• More satisfactory to patients
• Supported by 25 randomized controlled trials
• ACT is also called
• Training in community living
• PACT (Program for Assertive Community Treatment)
• Continuous treatment teams
• Intensive psychiatric community care (in VA
  system)

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Services Provided by ACT
Phillips 2001 Psych Services
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Principles of ACT
Phillips 2001 Psych Services
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Cognitive Rehabilitation for Schizophrenia

• Attention
• to increase attention span
• to improve the efficiency of information
  processing
• Various software programs
• Memory
• memory notebook, mnemonics, rehearsal
• Visuospatial skills
• Executive function
• To attempt remediation vs. adaptation

Heydebrand
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Cognitive Exercises How to Think
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CBT for Schizophrenia

• CBT is helpful for refractory or breakthrough
  psychotic symptoms
• Requires high insight (I cant trust my
  perceptions because I am sick.)
• CBT for delusions
• Direct confrontation should be avoided
• Focus not on the belief but on the evidence for
  it
• Encourage development of arguments against
  beliefs by patients

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CBT for Delusions
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CBT for Schizophrenia

• CBT for hallucination
• Distraction method (Extinguishing)
• Wearing headphones to focus attention away so the
  hallucinations are extinguished with decreased
  reactivity
• Focusing method (Desensitization)
• Describe, record and recognize the connection
  between stressors and hallucinations
• Explore what the voices mean to them
• Use self-talk to cope with hallucinations
• Negative symptoms
• Activity scheduling
• Skills training

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Activity Scheduling for Negative Symptoms
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Summary for Rehabilitation

• Psychiatric Rehabilitation requires teamwork
• Psychosocial treatments for schizophrenia can be
  evidence-based and individualized
• Psychosocial rehabilitation is critical,
  effective and efficacious

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Our Goals in Mental Health
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The Presidents New Freedom Commission on Mental
Health

• Achieving the Promise
• Transforming Mental Health Care in America
• July 2003

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President Initiative for Mental Health Care
Transformation

• In Feb 2001, the New Freedom Initiative was
  announced
• In April 2002, three obstacles preventing
  Americans from getting excellent mental health
  care were identified
• Stigma
• Unfair treatment limitations and financial
  requirements in private health insurance
• Fragmented mental health service delivery system
• The commissioners Hogan et al (21 experts)

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Proposed Goals for a Transformed Mental Health
System

• Americans understand that mental health is
  essential to overall health
• Mental health care is consumer and family driven
• Disparities in mental health care are eliminated
• Early mental health screening, assessment, and
  referral to services are common practice
• Excellent mental health care is delivered, and
  research is accelerated
• Technology is used to access mental health care
  and information

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Conte Center

• Devoted to conduct research in the etiology and
  treatment of mental illnesses such as
  schizophrenia
• Devoted to serve the community by
  seminars/newsletter/research participation
• First Contact Program
• Bases at Washington University, St. Louis

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Treatment-Resistant Illness

• Evaluate adequacy of medication trials
• Consider a trial of clozapine
• Consider augmenting medication
• Consider ECT
• Consider Cognitive Behavior Therapy