Are we entering a new era for treatment choice for schizophrenia?

22 February 2014

Our understanding of schizophrenia and related psychotic disorders is changing. Traditionally these conditions have been viewed as purely biological in nature, not linked to personal life experiences in any way, and only treatable with medication. These views have been shaken by accumulating research findings that have emerged over the last 20 years.

There is now incontrovertible evidence that has established that far from psychosis being incomprehensible, there is a clear link between schizophrenia and childhood adversity. There is also a recognised 'dose' effect that shows that when the adversity is more severe or prolonged, the chance of developing psychosis rises.

The relationship is akin to that of smoking and lung cancer - there is a strong association but just as not everyone who smokes develops cancer so trauma doesn't always lead to psychosis; and in the same way that not everyone who develops lung cancer has been a smoker so psychosis can develop without adversity.

This revised understanding of psychosis challenges traditional approach to treatment too. Not only are symptoms understandable, but treatment may need to go beyond medication to consider and make sense of symptoms within the context of a person's own life experiences.

In 2003, the National Institute for Health and Care Excellence (NICE) which advises on the most effective and efficient treatments, recommended that everyone with a diagnosis of schizophrenia should be offered psychological interventions, namely Cognitive Behavioural Therapy (CBT) and Family Interventions.

These interventions were found to reduce symptoms and relapses when used in conjunction with medication. Whilst evidence has grown to support the use of psychological therapies in the treatment of psychosis, there has been a growing recognition of the limits of antipsychotic medication.

A significant proportion of those prescribed this type of treatment do not respond to it, moreover antipsychotics are linked to some significant side effects including weight gain and cardiovascular problems. It is now recognised that antipsychotics can contribute to the risk of early mortality, with recent studies revealing that people with psychotic disorders have a decreased life expectancy of up to 20 years compared with the general population.

Although not a panacea for all, many people with schizophrenia report that their lives have been transformed by psychological therapy. Unfortunately only about ten per cent of those who should be offered CBT get access to this form of treatment. Service users with psychosis have been asking for treatment choice: to be able to choose psychological therapy with medication or as a stand-alone treatment without antipsychotics.

To date, no gold standard research has been conducted to evaluate whether psychological therapies could be effective if delivered without antipsychotics. As a result of the lack of evidence, even when this treatment has been available, there has been a reluctance to offer this as a treatment option.

New research published in The Lancet challenges this perspective. The trial of CBT for people with psychosis not taking antipsychotic medication has demonstrated that psychological therapy on its own can help people with schizophrenia and related disorders.

For many this trial will provide hope that we are approaching a new era in treating schizophrenia where true treatment choice is a reality.

 search domain-b