Schizophrenia Treatment Outcomes: An Evidence-Based Approach to Recovery

351 Pages·2020·5.366 MB·English

by  Amresh Shrivastava, Avinash De Sousa

Schizophrenia
Treatment Outcomes
An Evidence-Based Approach
to Recovery
Amresh Shrivastava
Avinash De Sousa
Editors
123
Schizophrenia Treatment Outcomes
Amresh Shrivastava • Avinash De Sousa
Editors
Schizophrenia
Treatment Outcomes
An Evidence-Based Approach
to Recovery
Editors
Amresh Shrivastava, MD, DPM Avinash De Sousa, MD, DPM, MS
Lawson Health Research Institute Lokmanya Tilak Municipal
Western University Lawson Health Medical College
Research Institute De Sousa Foundation
London, ON Mumbai
Canada India
ISBN 978-3-030-19846-6 ISBN 978-3-030-19847-3 (eBook)
https://doi.org/10.1007/978-3-030-19847-3
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Foreword
Thinking About Therapeutics for Persons
with Schizophrenia
This book addresses many aspects of clinical care relevant for persons with a
diagnosis of schizophrenia. Organized around the evidence gathered within
schizophrenia, the various chapters will prove relevant for many psychotic
disorders. It is impossible to be comprehensive since there are so many vari-
ables involved and so much variation between patients. But this is the most
comprehensive effort to date, with presentations in a brief and understandable
framework. This foreword provides a view on concepts related to understand-
ing schizophrenia and the integration of therapeutics at the individual level.
The Biopsychosocial Medical model provides the framework for integrat-
ing patient-centered information. This model calls attention to levels in
human function where therapy can be initiated. More fundamentally, the
model is a general systems concept calling for integration across each level.
For example, if blushing were a disease, a vascular physiologist could explain
the physiology of reddening of the face, but the causative role of shame is
understood at the psychological level, and why the blush occurs in public
requires explanation at the social level. So it is with schizophrenia, where a
cognitive intervention at the psychological level seeks understanding of
effects on brain physiology and simultaneously observes effects on social
cognition and function.
Conceptualizing schizophrenia is important, and for too long the field has
held the view that schizophrenia is a disease or, to be more specific, a brain
disease. A brief history will clarify. Kraepelin initiated this view with demen-
tia praecox and put in place the expectation of a chronic and deteriorating
course. He held that dissociative pathology and weakening of the wellsprings
of volition were the core pathologies that, together with a poor prognosis,
defined a disease entity. Bleuler proposed that the dissociative pathology was
the core pathology in all cases of schizophrenia, hence meeting the concept
of a specific disease entity based on shared pathophysiology. Bleuler, by the
way, viewed hallucinations and delusions as secondary pathologies and not
core manifestations of schizophrenia. This, with the defining of manic-
depressive psychosis, places conceptual approaches to schizophrenia in the
disease entity category. In the 1960s and 1970s the observations of substan-
tial heterogeneity in development, manifestation, and course challenged the
v
vi Foreword
single disease concept. This heterogeneity may be the result of a broad,
overinclusive diagnostic practice. An alternative view held that nuclear or
true schizophrenia based on specific criteria provided a disease entity consis-
tent with the concept following Kraepelin and Bleuler. But note that the key
diagnostic criteria advocated were symptoms of first rank described by
Schneider as meaning the presence of schizophrenia in the absence of delir-
ium. These special forms of hallucinations and delusions quietly shifted the
concept from dissociative pathology and avolition to reality distortion. This
view was sufficiently influential for DSM-III in 1981 to highlight these first-
rank symptoms as sufficient to meet the A criteria. Negative symptoms were
omitted altogether.
The International Pilot Study of Schizophrenia was initiated in 1968 to
determine if schizophrenia was similar in different locations. Similar cases
were found in all nine countries, but a broader concept was used in some
centers, including the NIMH center where John Strauss, John Bartko, and I
were working. We found the Schneiderian first-rank symptoms in bipolar and
other psychotic conditions in our center and confirmed in other centers.
Dividing our broad schizophrenia sample into nuclear or true schizophrenia
versus pseudo schizophrenia, we falsified the developmental and course pre-
dictions based on first-rank symptoms. Our conclusion was that schizophre-
nia is a clinical syndrome rather than a specific disease entity and that the
study of schizophrenia required deconstruction and the component parts were
the targets for discovery and for clinical application. These conclusions were
published in 1974 [Strauss JS, Carpenter WT Jr, Bartko JJ. The diagnosis and
understanding of schizophrenia. Part III. Speculations on the processes that
underlie schizophrenic symptoms and signs. Schizophr Bull. 1974 Winter;
(11):61–9] but failed to influence DSM-III, and it was not until DSM-5 that
first-rank symptoms lost their special status and schizophrenia as a clinical
syndrome was made explicit. While schizophrenia as a disease is still in com-
mon use, the twenty-first century has brought a major shift to the clinical
syndrome view, with science moving rapidly to deconstruction, and clinical
application aimed at specific aspects of psychopathology and function, with
diagnosis only as a starting point. There is wide recognition that symptoms
cross diagnostic boundaries. It is within this clinical syndrome concept that
the present book addresses schizophrenia.
The 29 chapters in this book inform the reader on many of the conceptual
issues and therapeutic opportunities in the clinician’s tool box. Individuals
with a schizophrenia diagnosis will vary in which domains of pathology are
present and what functional areas need to be addressed. Chapters range from
pharmacotherapy to pathways and approaches for recovery; from directly
addressing impairments to approaches based on compensatory and resilience
mechanisms; from medical attention to metabolic and comorbid pathology to
peer support and holistic approaches; from individual issues such as suicide
and cannabis use to population issues such as challenges in low-income
countries and therapeutics at different life stages. And much more.
Persons with a diagnosis of schizophrenia face many challenges in life,
and these vary across individuals. Clinical care must identify and address the
full range, and this book provides critical knowledge on many of the issues
Foreword vii
common to this diagnosis. Integration of these many elements is difficult.
Low-income countries lack the professional workforce and financial ability,
but some remarkable programs are developed. High-income countries some-
times provide support for integrated care of the mentally ill. But many patients
are treated in circumstances where the care advocated in this book is simply
not available. The USA is a sad example of not providing a medical system
that integrates the essential clinical care elements.
The busy clinician cannot be knowledgeable in the full range of issues that
require therapeutic attention. Questions about the use of cannabis will arise.
One patient avoids social encounters because of stigma, another has suicidal
thoughts, and others will not understand the role of metabolic effects of life-
style and medications, nor appreciate the role of physical exercise. The clini-
cian needs to address a shortened life expectancy and which therapies and
behavioral changes can reduce risk. How is sleep disturbance to be addressed?
And what special form of CBT is required for each symptom? It is in the
context of so many therapeutic issues that the present book provides critical
information in 29 chapters. Each chapter addresses a specific issue allowing
the reader to focus on specific needs for information. This book provides
much information on what is needed and how to effect clinical application.
William T. Carpenter Jr., MD
Professor of Psychiatry
Maryland Psychiatric Research Center
University of Maryland School of Medicine
Baltimore, MD, USA
Preface
Schizophrenia is a neurobehavioral disorder which affects about 0.7–1% of
people in the world. The plight of patients suffering from schizophrenia has
been due to stigma as well as poor access to care. Both of these factors lead
to treatment resistance. We could never find a convincing and effective treat-
ment for schizophrenia until the last 25 years, when both pharmacotherapy
and psychosocial treatments started showing a remarkable change in the life
of such patients. Though effective treatments have been available, it has been
very difficult to extend the benefit to a large number of people.
On one side we are lacking directions in the search for specific treatments
for schizophrenia, and on the other side we have serious limitations in health
systems management and capacity-building for the disorder. We will be
excited the day we get a treatment which will change the lives of patients with
schizophrenia; however, we will remain worried to take such treatments to
people. More specialized treatments are more complex, and it requires spe-
cially trained therapists. Besides, these psychosocial treatments are no less
expensive than newer medication. More patients live in the less privileged
parts of this world, and thus treatments have to be effective but at the same
time should be within reach of patients.
With more facilities, awareness, and changes in the socioeconomic situa-
tion, there is increased hope and expectation, and thereby newer demands by
the relatives, service users, and caregivers. The scientific community has
responded to such requirements and several social treatments are being tried
in unique settings, which keeps patients close to their families and away from
the hospital while encouraging them to seek employment, develop relation-
ships, have a positive attitude, and becoming economically productive. These
treatments have goals which restore dignity and promote human rights of
these patients while setting a higher benchmark and encouraging clinicians to
achieve the same.
We have compiled this book in order to provide specifics of each of the
psychosocial treatments currently used in schizophrenia, based upon the
recovery model. We are thankful to all our contributors who have taken
extraordinary care to keep the chapters focused and to the point so that clini-
cians as well as students find it easy to read and practice it in their patient
care. The book also deals with the conceptual issue as well as controversies
but not beyond a point.
ix
x Preface
All chapters highlight the opinion, experiences, and evidence for recovery
in schizophrenia. We thank all our authors and coauthors for their valuable
contributions in the making of this handbook. We hope that this book makes
interesting reading for everyone.
London, ON, Canada Amresh Shrivastava, MD, DPM
Mumbai, India Avinash De Sousa, MD, DPM, MS
Contents
Part I R ecovery and Return to Wellness
1 Among Patients with Schizophrenia: A Learning Curve
for Psychiatrists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Avinash De Sousa and Amresh Shrivastava
2 Living Healthy with Schizophrenia: A Consumer’s Approach . . 9
Michael Alzamora
Part II C urrent Status of Outcome, Recovery
3 Gender and Outcome in Schizophrenia . . . . . . . . . . . . . . . . . . . . 15
Mary V. Seeman
4 Outcome of Schizophrenia in Low- and Middle-Income
Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Thara Rangaswamy, Greeshma Mohan, and Vijaya Raghavan
5 Neurocognition and Treatment Outcomes in Schizophrenia . . . 35
Juan Molina and Ming T. Tsuang
6 Cannabis and Recovery in Schizophrenia . . . . . . . . . . . . . . . . . . 43
Benjamin McLoughlin
Part III Conceptual Issues in Recovery of Schizophrenia
7 Concept and Model of Recovery . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Larry Davidson, David Roe, and Janis Tondora
8 A Model and Evidence Base for Achieving Complete
Recovery in Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Ananda K. Pandurangi
9 Biological Markers for Outcome and Recovery
in Schizophrenia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Damodharan Dinakaran, Vanteemar S. Sreeraj,
and Ganesan Venkatasubramanian
10 Outcome Measurement in Schizophrenia: Challenges
and Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Sandeep Grover and Swapnajeet Sahoo
xi