1. What is the course and prognosis of schizophrenia patients?
The course of schizophrenia may vary after the initial onset of remission. About 1/3 of patients are clinically cured, i.e., they no longer have psychopathic symptoms. However, even among these “recovered” patients, they may find that their sense of self changes after recovery because of the profound impact of schizophrenia on their normal lives and experiences.
Other patients may have an episodic course, with episodes and intervals of varying length and relapses of varying frequency, with relapses related to psychosocial factors. Unlike depression and mania, which have complete remission, schizophrenia has no abrupt shift or clear boundary between episodes and discontinuations.
Some patients may experience personality changes and decreased social functioning after recurrent episodes, presenting clinically with varying degrees of disability. When the disability is mild, the patient retains some ability to adapt to society and work.
In a small percentage of patients, the disease progresses progressively, or each episode causes further personality decline and disintegration. The worsening of the disease eventually leads to prolonged hospitalization or repeated hospital admissions.
Overall, 75% of patients with a first episode of schizophrenia can be cured and about 20% remain healthy for life. Thus the prognosis for schizophrenia is not as pessimistic as one might think. Due to continuous advances in modern therapeutics, about 60% of patients can achieve social remission, i.e., some social functioning.
For a specific patient, it is more difficult to determine the prognosis in the early stages of the disease. Some of the factors that favor prognosis are: late age of onset, acute onset, significant affective symptoms, normal personality, good pre-morbid social and adaptive skills, and a strong psychogenic relationship between the onset of the disease. The prognosis is usually better for women than for men.
2.What are the clinical treatment goals for schizophrenia?
Acute phase treatment goals.
① Eliminate major symptoms and strive for clinical remission;
②Prevent the occurrence of suicide and impulsive behavior;
③Minimize adverse drug reactions and prevent the occurrence of serious adverse reactions;
④Prepare for the restoration of social function and return to society.
Treatment goals during the consolidation and stabilization period.
①Prevent the relapse of symptoms;
②Control of post-schizophrenic depression or obsessive-compulsive symptoms;
③Prevent suicide;
④Control and prevent long-term adverse drug reactions;
⑤ Promote return to society.
Maintenance treatment goals for relapse prevention.
①Prevent relapse and deterioration of the disease;
②Improve patient compliance with treatment;
③Restore social function;
④ Enhance the ability to cope with physical illness and psychological stress.
3. How to master the treatment strategy of schizophrenia in the acute stage?
1. Conduct a comprehensive examination to clarify the diagnosis and make a baseline assessment before treatment, including mental status, severity of symptoms, physical condition, and laboratory tests such as electrocardiogram, electroencephalogram, blood and urine routine, liver and kidney function, blood glucose, lipids and other biochemical indicators. The baseline assessment will provide comparative information for future efficacy assessment and determination of adverse reactions, so that the treatment plan can be adjusted and corresponding measures can be taken.
2. Intensive drug therapy should be carried out to seize the effective time for treatment and strive for the best prognosis. Choose drugs that are potent, safe and have a high benefit/risk ratio before treatment. Beneficial for future social function recovery. The treatment mode is selected according to the severity of the patient’s mental condition, whether the patient is cooperative or not and the treatment environment conditions.
If the patient is quiet and cooperative, and the condition is mild or moderate, oral administration of the medication can ensure treatment. If the patient is excited, agitated or uncooperative, it is advisable to give the drug by injection within 1-2 weeks to ensure the implementation of the acute treatment, and then change to oral drug administration after the condition is controlled.
3, according to the condition, family care conditions to choose the treatment site. If the disease is mild and there is someone at home to take care of it, outpatient and/or community treatment can be considered; if the disease is severe, uncooperative or there is no one at home to take care of it, inpatient treatment is recommended.
4. Depending on the patient’s discomfort with the emergent pathological experience and unfamiliarity with the treatment environment, general supportive psychotherapy such as care, understanding, support and assistance should be provided. Educate the patient’s relatives about the disease and treatment, help the patient’s family cope with the reality of their loved one’s illness, and establish a therapeutic alliance with the physician for a 6-8 week course of treatment.
4.How to master the treatment strategy for the stable phase of schizophrenia?
After patients have been treated in the acute phase and their symptoms have been relieved, attention should be paid to consolidating treatment to stabilize the disease.
1.Treatment with the effective dose of the original effective drug should be the main treatment for 3-6 months.
2.Treatment sites include home (outpatient), community, rehabilitation ward or rehabilitation base.
3.Family education and psychotherapy. The goal is to increase the patient’s ability to understand the disease and treatment; to improve the cooperation, compliance and social adaptability to treatment, as well as self-care ability. Group psychotherapy, cognitive therapy, skills training and behavioral therapy can be adopted.
5.How to master the treatment strategy for the maintenance period of schizophrenia?
After the above treatment, the patient’s condition is basically in remission and the general performance is normal, adhere to maintenance treatment to prevent relapse and deterioration of the condition.
(1) Continue the original effective drug therapy, adjust the dose as appropriate, grasp the dose of relapse prevention, and do not change the drug as much as possible if there are no special adverse reactions.
(2) The course of treatment will be determined as appropriate.
(3) Treatment sites, mainly family (outpatient) and community treatment.
(4) Strengthen psychotherapy, seek social support and return to society.
6.How to deal with drug-refractory schizophrenia?
Drug-refractory schizophrenia does not have a precise definition, but generally refers to those who have been ineffective after a full course of three different types of antipsychotic drugs.
Treatment should pay attention to.
(1) Revisit the original schizophrenia diagnosis to further rule out other disorders.
(2) Perform blood concentration measurements, if necessary, to clarify the patient’s compliance with medication and whether the patient has problems with drug metabolism.
(3) Reformulate the treatment plan, including: increasing the dose, changing medication, combining medication or combining booster therapy, and also consider electroconvulsive therapy.
(4) Treatment course of no less than 2-5 years.
Chronic schizophrenia, sometimes overlaps with refractory schizophrenia, but the two should not be the same concept. The former is mostly dominated by negative symptoms, while the latter may refer to distinct positive symptoms and ineffective treatment, and treatment measures are similar for both.
7.What are the basic principles of drug treatment for schizophrenia?
Once the diagnosis is confirmed, medication should be started; a single medication is appropriate; attention should be paid to the special situation of individual patients in treatment, and medication should be individualized; a small dose should be started, and the titration rate of medication should be determined according to the change in condition and tolerance and the place of treatment. If the condition is urgent and serious, the physical condition is good and tolerable, and the hospitalization has good monitoring conditions, you can titrate rapidly to the effective dose; strive for a full amount and full course of treatment; review regularly, carefully assess the efficacy and adverse reactions, and actively adjust the treatment plan.
8.How do patients with schizophrenia receive standardized drug treatment?
Antipsychotic drugs can be divided into classical drugs and non-classical drugs according to their mechanism of action. Classical drugs, also known as neural blockers, mainly play an antihallucinatory and delusional role by blocking D2 receptors, and are divided into two categories: low and high potency according to clinical characteristics.
The former is represented by chlorpromazine, which has strong sedative effect, obvious anticholinergic effect, greater cardiovascular and hepatic effects, less extrapyramidal side effects, and larger therapeutic doses; the latter is represented by haloperidol, which has prominent antihallucinatory and delusional effects, weak sedative effect, little cardiovascular and hepatic toxicity, but greater extrapyramidal side effects.
In recent years, non-classical antipsychotic drugs have been introduced to play a therapeutic role through the balanced blockade of 5-HT and D2 receptors, which are effective not only for positive symptoms such as hallucinations and delusions, but also for negative symptoms such as emotional flatness and hypoactive will. The representative drugs are risperidone, olanzapine, quetiapine, clozapine and others.
Schizophrenia drug treatment should be systematic and standardized, emphasizing early, adequate amount and full course of “whole-course treatment”. Once the diagnosis is clear, medication should be started early. Medications should be administered at therapeutic doses, and generally the acute phase of treatment lasts for 2 months.
Some patients, family members and even doctors are overly worried about adverse drug reactions and tend to take low doses of drugs, so that the symptoms are not controlled for a long time and do not achieve the desired therapeutic effect. Treatment should start with a low dose, gradually increase the dose, and pay close attention to adverse reactions at high doses. The dose of medication for outpatients is usually lower than that for inpatients, and generally cannot be stopped suddenly.
Maintenance therapy has a definite effect on reducing recurrence or re-hospitalization. Maintenance therapy should be given for 1 to 2 years for the first episode, and longer for the second or multiple relapses, or even for life. The dose of maintenance treatment should be individualized, and is generally 1/2 to 2/3 of the dose during the acute treatment period.
The American Schizophrenia Outcome Study Group concluded that the maintenance dose of classical antipsychotics should not be less than 300 mg/day (converted to chlorpromazine), otherwise the effectiveness of relapse prevention is reduced. The maintenance dose of non-classical antipsychotics is appropriately reduced compared to the acute phase of treatment, but there is a lack of well-established models as to how much to reduce.
Regardless of the acute phase or maintenance treatment, in principle, a single drug is used, and drugs with similar mechanisms of action should not be combined in principle. For patients with depressive mood, manic state and sleep disorders, antidepressants, mood stabilizers and sedative-hypnotics can be used as appropriate, and benzhexol hydrochloride (Antan) can be used in combination with extrapyramidal reactions.
9.How can schizophrenia patients undergo standardized psychotherapy?
Psychotherapy must be a part of schizophrenia treatment. Psychotherapy can not only improve the patient’s psychiatric symptoms, enhance self-awareness and compliance with treatment, but also improve the relationship between family members and facilitate the patient’s contact with society.
Behavioral therapy helps to correct some of the patient’s functional deficits and improve interpersonal skills. Family therapy allows family members to identify long-standing communication problems, helps to vent bad feelings, and simplifies communication styles.