Treatment Checklist

Schizophrenia is a treatable brain illness ranging from mild to severe forms. It is very diverse in its causes, symptom severity and outcome similar to different types of Parkinson’s disease or cancer. Persons with schizophrenia may have some similar features, but they also have different experiences.

For persons with schizophrenia, understanding and learning about the illness itself is vital. Therefore, consider investing some time learning about the biology and clinical aspects of the disease, and ask your psychiatrist and treatment team all the questions you can think of.

Over the past 50 years, the medical care of schizophrenia has shifted from an in-patient institutional setting to community-based care, except when a psychotic relapse occurs and hospitalization is necessary. Today, many, but not all, people with schizophrenia, can achieve significant improvement in their illness and can return to vocational and social functioning, especially with the help of long-acting injectable antipsychotic medications, which protect against relapse better than pills. Sometimes, other medications– like antidepressants or anti-anxiety medications– may also be needed.

For additional resources, we invite you to check out our website, https://curesz.org/what-is-schizophrenia/.

You should ask your psychiatrist to explain the illness and the various available treatments (including pills or intramuscular injections once every 1-6 months without having to take any pills) and he or she should assure you that all available treatments will be tried until you have achieved a return to your baseline. For about 30% of patients whose psychosis does not respond to the standard drug therapies, a medication called clozapine may be necessary. (See below, clozapine can eliminate hallucinations or delusions 50% of the time when other antipsychotics fail.) Once you start improving, your doctor and the mental health team should work with you to establish goals for the future, such as returning to school or work, spending more quality time with family and friends, and engaging in hobbies and other meaningful activities.

Recovery, not continued illness and disability, should be the goal for most patients who suffer from schizophrenia. See these stories of remarkable individuals who are thriving despite schizophrenia: https://curesz.org/survivors/

Adherence to antipsychotic medications in schizophrenia is very erratic leading to recurrence of psychosis, which are known to cause brain tissue loss, with clinical and functional deterioration and disability. Anosognosia (lack of insight) memory dysfunction, negative symptoms and substance use combine to preclude daily intake of oral medications. Fortunately, several long-acting injectable antipsychotics are available, eliminating the need to take pills every day. These include monthly injections (Invega Sustenna, Abilify Maintena, Aristada, Relprevv, Uzedy, Perseris), every 2 months (Abilify Asimtufii, Aristada), every 3 months (Invega Trinza) and every 6 months (Invega Hafyera). Ask your psychiatrist or nurse practitioner about these injectable formulations (some are intramuscular and some subcutaneous). They ensure that the brain receives medications without interruption, and are excellent alternatives to inconsistent adherence to daily pills. Avoiding psychotic relapses is critical to avoid brain damage, treatment resistance, incarceration and homelessness.

About long-acting injectable antipsychotic medications.
https://curesz.org/injectable-medications/

Studies show that several supplements added to antipsychotic medications during the acute episodes of psychosis may help in schizophrenia. These include omega 3 fatty acids (which may counteract the brain inflammation during psychosis), N-acetyl cysteine (which may help neutralize the harmful free radicals during psychosis), and vitamin D (which is important for brain development and ongoing health).

Since the 1990s, research has proven the effectiveness of CBT in depression, anxiety, and some symptoms of schizophrenia. It is considered one of the most effective psychotherapy methods.

About CBT from the Mayo Clinic.

About the “Recovery by Enabling Adult Carers at Home” (REACH) project: Psychosis REACH is a training that offers concrete, evidence-based skills for relatives and friends of individuals with psychotic disorders to better care for and relate to their loved ones. Psychosis REACH utilizes skills from Cognitive Behavioral Therapy (CBT) to teach caregivers to normalize and make sense of psychosis, use evidence-based coping strategies and develop key caring principles to communicate effectively with your loved one. To learn more, please visit our website: www.psychosisreach.org/

Clozapine can work when other antipsychotic medications fail to reduce persistent hallucinations or delusions. (These cases are called “treatment-resistant” or “refractory” cases).

Clozapine is associated with some side-effects. It can cause a reduction in white blood cell count in very rare cases (less than 1%). That’s why weekly white blood cells have to be measured with a quick blood test. Clozapine also may cause increased appetite and weight gain, sleepiness, constipation, and increased salivation. In high doses, it may cause other problems, such as diabetes or seizures, but most people do not need high doses.

Because patients on clozapine must be monitored for side effects, some psychiatrists avoid using clozapine– or use it rarely. In the United States, while 25% of patients may benefit from a trial of clozapine, less than 5% actually receive it from their psychiatrist and may need to be referred to a clozapine expert.

All patients who have not achieved full remission — which means they are asymptomatic or nearly free of delusions or hallucinations — with two different antipsychotic drugs, deserve a trial of clozapine.

Clozapine. https://curesz.org/resources/clozapine-experts-panel/

Several studies show the benefit of exercise (walking 30 minutes a day) to help lose weight, improve cardiac health, and stimulate the production of new brain cells. Studies also show the benefit of a healthy diet (low calorie and low fat, with fiber from fruits, vegetables, and nuts) to avoid weight gain and reduce the risk of diabetes and high blood pressure, which are very common in schizophrenia.

Brain health. https://www.youtube.com/watch?v=kdeiZ4lmbd0

When your doctor prescribes a medication, ask what you should do if an intolerable side effect occurs. If you are experiencing side effects from your medication, do not stop your medications abruptly; get in touch with your doctor right away. The muscle stiffness can improve with a modest reduction of the dose. Discontinuing medications can lead to psychotic relapses, and in some cases, it can cause withdrawal symptoms like insomnia or agitation or muscle twitching. Additionally, psychiatric medications become less effective after each recurrence.

There are 12 new generation antipsychotic medications available today. If you are experiencing side effects, know that there may be another medication that may suit you better. Every person’s experience with medication is different because our bodies are biologically different.

Psychoeducation and Recovery.
https://www.youtube.com/watch?v=zBleQcp4xGo

Tardive Dyskinesia (TD) is an involuntary movement disorder which is a serious neurological side effect of all antipsychotic medications, but especially older (and harsher) antipsychotics drugs like haloperidol. TD’s movements are often seen in the face, including the tongue lips, jaw and eyes (blinking/grimacing) but can also affect the neck, trunk, arms, fingers, legs, toes, and diaphragm.

Fortunately, two effective medications for TD were recently approved by the FDA. Valbenazine was approved by the FDA in April 2017, and deutetrabenazine was subsequently approved in August 2017. These medications can significantly reduce or eliminate TD movements.

Because the older antipsychotics like haloperidol are much more likely to cause acute muscle stiffness, tremor, rigidity or restlessness (in the first few hours, days, or weeks), and a high rate of TD (usually many years of use), they generally should not be used to treat schizophrenia or bipolar disorder. The newer antipsychotics have a much lower rate of TD.

Tardive dyskinesia.
https://curesz.org/tardive-dyskinesia/