Schizophrenia Treatment Should Focus On Recovery, Not Just Symptoms

Functional outcome, not merely symptom relief, should be the clinical focus in the treatment of schizophrenia, said Stephen Marder, M.D., in an address titled “Recovery in Schizophrenia” at last month's Institute on Psychiatric Services in Atlanta.

Marder called for a new focus by psychiatrists on the physical health of patients with schizophrenia and incorporation of the broad range of proven psychosocial treatments. He also called for a new research agenda aimed at developing drugs to treat cognitive deficits—the feature of schizophrenia most strongly associated with functional outcome (see box on page 37).

The sum of those recommendations is a new orientation toward recovery, which Marder described as a process—not an end-point—in which a patient can engage throughout the stages of illness even as he or she retains some symptoms.

This orientation marks a fairly major departure from standard psychiatric care, which Marder said has overemphasized pharmacotherapy of positive symptoms and underutilized proven psychosocial treatments, while all but ignoring the substantial medical complications confronting patients with schizophrenia.

“We need to have a paradigm of treatment that focuses on functional outcome as the most important outcome, with symptoms as things to be concerned about,” Marder said. “We need to use both psychosocial and pharmacologic treatments. And I believe that psychiatrists and mental health care providers need to take more responsibility for the physical health of our patients, a serious problem that up until now has not been adequately addressed.”

Marder is director of the section on psychosis of the UCLA Neuropsychiatric Institute and a professor of psychiatry at the David Geffen School of Medicine at UCLA.

For five decades, treatment of people with schizophrenia has largely relied on pharmacotherapy, and while those drugs have relieved much suffering, functional outcomes are not much improved from the point when antipsychotics were first introduced, Marder said.

“If a goal is [getting patients back to] work, only about 20 percent of patients with schizophrenia are currently working,” Marder said.“ And clinical practice, as it is engaged in clinics and hospitals, is largely focused on symptoms.”

Marder emphasized that better treatment of cognitive deficits—not merely amelioration of symptoms—is the key to improving functional outcomes in people with schizophrenia.

“Symptoms can be handicaps on the way to recovery, but people can recover who have symptoms,” he said.“People can work who experience hallucinations and have suspicious thoughts, just as people can recover and prosper if they are missing a limb. It's a handicap, not the endpoint of treatment.

“Patients need to be at the center and be active partners in setting goals of treatment,” he said. “But one of the obstacles is American psychiatry. Our focus on symptoms and away from the functional recovery that patients are asking for is why there is this controversy. Patients and families are asking for a recovery model, and we need to respond.”

Marder outlined the psychosocial treatments that have a literature of efficacy behind them when combined with antipsychotic medication. These include illness education, family interventions, supported employment, assertive community treatment, skills training, and cognitive-behavioral therapy.

He emphasized that evolving research on psychosocial therapies has shown that they act on different aspects of the patient's illness than do medications. For instance, he described studies showing that skills training had no impact on relapse, but had a profound effect on social outcome and patient quality of life.

He also stressed that the effects of psychosocial treatment are generally not seen in the short term. “Psychiatrists underestimate the effectiveness of these treatments because patients don't receive them long enough,” Marder said.

He especially highlighted the importance of supported employment. “No treatment I have seen is as effective as a part-time job,” Marder said.“ Nothing contributes as much to self-esteem and community integration than being able to interact with co-workers on a regular basis, and there is nothing more reinforcing to a patient than being given a positive review by a supervisor and being paid for one's work.”

Marder said a most urgent change necessary in the treatment of schizophrenia is a new attention on the part of mental health professionals to the medical complications typically seen in the disease.

Patients with schizophrenia have a high smoking rate and are at higher risk for obesity, diabetes, and hypertension. He said the average lifespan for a patient with schizophrenia is 15 years less than the general population.“ The increased risk for suicide has little to do with it,” he said. “Our patients are dying of heart disease.”

Marder described a conference on the subject in late 2002 at Mount Sinai University School of Medicine in New York that brought together a host of experts on schizophrenia, diabetes, heart disease, and preventative health, among other topics.

Consensus recommendations developed at the conference called for regular monitoring of body mass index, plasma glucose level, lipid profiles, and signs of prolactin elevation or sexual dysfunction—all of which should guide the selection of antipsychotic agents (Psychiatric News, March 5, September 17).

Specific recommendations were made for cardiac monitoring of patients who receive medications associated with QT interval prolongation and for monitoring for signs of myocarditis in patients treated with clozapine. Patients who receive both first- and second-generation antipsychotic medications should be examined for extrapyramidal symptoms and tardive dyskinesia. Patients with schizophrenia should also receive regular visual examinations, according to the recommendations. These recommendations appeared in “Physical Health Monitoring of Patients With Schizophrenia” in the August American Journal of Psychiatry.

“Implementing these recommendations in a psychiatric setting isn't going to be easy, but it is self-evident that it should be happening,” Marder said. “The treating psychiatrist may not be able to manage many of these medical problems, but they need to be certain that someone does.” ▪