Schizophrenia is a chronic and severe mental disorder that affects how a person thinks, feels, and behaves. The main symptoms of schizophrenia include hallucinations, delusions, disorganized thinking and speech, and impaired cognitive functioning. Schizophrenia typically begins in late adolescence or early adulthood. The exact causes of schizophrenia are unknown, but research suggests a combination of genetics, brain chemistry, and environment contributes to development of the disorder.
While there is no cure for schizophrenia, various treatments can help manage symptoms. Treatment is usually centered around antipsychotic medications and psychosocial therapies. In recent years, research has led to newer antipsychotic drugs and specialized psychosocial interventions that may improve outcomes for people with schizophrenia. This article will provide an overview of the newest and most promising treatments for schizophrenia that have emerged over the past decade.
Newer Antipsychotic Medications
Antipsychotic drugs, also known as neuroleptics, are the primary medical treatment for schizophrenia. They work by blocking dopamine receptors in the brain, which regulates thinking and emotional response. The first antipsychotics were introduced in the 1950s. While these first-generation antipsychotics could help control positive symptoms like hallucinations and delusions, they often caused unwanted side effects like involuntary body movements (extrapyramidal side effects) and tremors.
Over the past 20-30 years, newer second-generation antipsychotics have been developed. These newer medications can control positive symptoms with fewer extrapyramidal side effects. Some of the newest antipsychotic drugs approved for schizophrenia treatment include:
Lurasidone
– Approved by FDA in 2010.
– Seen as effective for treatment of schizophrenia in clinical trials.
– May have lower risk of weight gain, diabetes, and lipid changes compared to some other second-generation antipsychotics.
– Common side effects are sleepiness, Parkinsonism, akathisia, nausea.
Asenapine
– Approved by FDA in 2009.
– Available as a twice-daily sublingual tablet or daily patch.
– Thought to have fewer metabolic side effects than other atypical antipsychotics.
– Common side effects are sedation, weight gain, oral hypoesthesia (reduced sense of touch in mouth).
Iloperidone
– Approved by FDA in 2009.
– Unique binding profile suggested to reduce risk of EPS and prolactin elevation.
– Lower akathisia rates than risperidone and placebo in trials.
– Common side effects are dizziness, dry mouth, fatigue, nasal congestion.
Paliperidone
– Active metabolite of risperidone, approved by FDA in 2006.
– Available as once-monthly injection after initial oral dosing.
– Thought to have lower prolactin elevation and higher efficacy than risperidone.
– Common side effects are insomnia, headache, weight gain.
Aripiprazole
– Approved by FDA in 2002.
– Partial dopamine agonist with unique mechanism of action.
– Displays efficacy against positive and negative symptoms.
– Thought to have less weight gain and metabolic disruption than other atypical antipsychotics.
– Common side effects are akathisia, insomnia, nausea, vomiting.
While the newer antipsychotics represent an improvement over earlier medications, there is still room for advancement. Ongoing research aims to develop antipsychotics with better efficacy against negative symptoms and cognitive deficits with fewer metabolic and motor side effects.
Long-Acting Injectables
In addition to new chemical agents, the formulation of antipsychotic medications has evolved in recent years. Long-acting injectable (LAI) forms of antipsychotics have become available as an alternative to daily oral medication. LAI antipsychotics include:
– Fluphenazine decanoate
– Haloperidol decanoate
– Paliperidone palmitate
– Aripiprazole lauroxil
With LAIs, the medication is administered via injection by a healthcare provider every 2-6 weeks. LAIs ensure stable delivery of medication over an extended period. Some benefits of LAI antipsychotics include:
– Avoiding daily medication and inconsistent adherence
– Steady medication levels, avoiding fluctuating symptoms
– Ability to track adherence by appointment schedule
– Elimination of first-pass metabolism for more predictable dosing
However, disadvantages of LAIs include:
– Inability to adjust or discontinue dose immediately
– More painful administration method
– Risk of relapse if appointments are missed
Overall, LAIs provide a convenient option for maintenance treatment. They are primarily used for patients who struggle with consistent adherence to oral medication. Recent research found LAIs reduced hospitalization risk by 30-50% compared to oral antipsychotics.
Early Intervention
Another recent advancement is early intervention programs focused on the initial period of psychosis. It’s believed that quicker treatment after the first emergence of psychosis may improve long-term outcomes. Specialized early intervention services involve:
– Public education to promote earlier recognition of symptoms
– Rapid access to psychiatric treatment after experiencing first psychotic episode
– Prescription of low-dose antipsychotics
– Psychosocial treatments like family education, supported employment/education
– Efforts to reduce delays before first treatment
In one major UK study, early intervention services reduced hospitalization risk by 50% during the first 2 years of treatment. With emergence of psychosis typically occurring around ages 18-24, rapid initiation of care during this critical period may alter the course of the disorder. Many regions now provide specialized early psychosis programs based on these principles.
Cognitive Remediation
In addition to positive symptoms like hallucinations, schizophrenia also causes cognitive deficits in areas like attention, concentration, memory and problem solving. These cognitive symptoms largely account for the functional disability associated with schizophrenia.
Cognitive remediation is a behavioral treatment targeting these cognitive deficits, usually delivered alongside standard medication and psychosocial interventions. Cognitive remediation involves repetitive practice and learning of mental exercises to strengthen neurocognitive skills.
Sessions are led by a trained instructor and conducted either one-on-one or with a small group of patients. Computerized training programs are also sometimes used. These interventions aim to improve cognitive abilities that are important for daily functioning and occupational rehabilitation.
Meta-analyses of clinical trials show cognitive remediation can lead to moderate improvement in areas like memory, attention, and problem solving. The benefits are enhanced when paired with other psychiatric rehabilitation programs.
Cognitive Behavioral Therapy for Psychosis (CBTp)
Cognitive behavioral therapy for psychosis (CBTp) is a specialized form of talk therapy tailored for schizophrenia treatment. The main goals of CBTp are to:
– Improve coping with distressing psychotic symptoms
– Modify delusional beliefs and paranoid thinking patterns
– Enhance functioning and quality of life
CBTp includes components like:
– Psychoeducation to normalize psychotic symptoms
– Behavioral experiments to test validity of delusions/hallucinations
– Development of coping strategies for symptoms
– Addressing low self-esteem and social isolation
CBTp is delivered one-on-one by a trained therapist, usually for 30-60 minute sessions over 6 months to 1 year.
Clinical trials demonstrate CBTp as an effective adjunctive treatment for schizophrenia. Meta-analyses show CBTp can:
– Reduce hospitalizations by 26% over 1 year
– Decrease symptom severity scores by 25% more than standard care alone
– Improve social functioning and global outcomes
Accordingly, CBTp is now recommended in schizophrenia treatment guidelines as part of a multi-modal approach alongside medication and family support.
Family Interventions
Schizophrenia greatly impacts not just patients themselves, but their loved ones as well. Educating and actively engaging family members in treatment has been a focus of recent research. Family interventions typically involve multiple family members participating in therapy sessions to:
– Provide education about schizophrenia
– Improve family communication and problem-solving skills
– Reduce criticism or hostility within family environment
– Teach strategies for handling disorganized behavior and psychotic episodes
Family therapy helps reduce stress and conflict stemming from the patient’s illness. It gives family members skills to support recovery and enhances the home environment.
Reviews of clinical trials indicate family interventions can:
– Reduce relapse and rehospitalization rates by 20%
– Lessen family burden and distress
– Improve patient functioning and social relationships
Accordingly, practice standards emphasize including family members throughout the treatment process. Family therapy is considered a critical element of the psychosocial rehabilitation process.
Specialized Housing
Finding appropriate housing is often a major challenge for people with schizophrenia. Becoming homeless or incarcerated is unfortunately common among individuals with severe, persistent mental illness. Supported housing services aim to provide more suitable living environments tailored to those with schizophrenia and other serious psychotic disorders.
Supported housing options include:
– Supervised group home/residential facilities with onsite staff support
– Semi-independent apartments clustered within a single building or complex
– Rental subsidies paired with assertive community treatment (ACT) teams
– Roommate matching services with shared housing in private apartments
– Temporary respite beds for acute symptom stabilization
These supported housing programs emphasize principles like client choice, recovery-focused services, community integration, and flexible support levels. Studies show supportive housing initiatives can:
– Increase housing stability and reduce homelessness
– Lower hospitalization rates up to 29%
– Improve quality of life and community functioning
– Reduce health service costs overall
Access to safe, stable and affordable housing is a major factor in recovery-oriented care. Expansion of supported housing services remains an important priority.
Assertive Community Treatment
Assertive community treatment (ACT) involves intensive outpatient services delivered by a multidisciplinary team. ACT teams typically include psychiatrists, nurses, social workers, substance abuse counselors and other clinicians.
Some features of ACT programs include:
– High staff-to-patient ratio
– 24/7 availability for crisis response
– Delivery of services in community settings instead of office visits
– Holistic support with mental health care, employment, housing, case management, etc
ACT is oriented around providing comprehensive treatment while allowing patients to live independently in the community. ACT teams maintain consistent contact and continuously monitor mental status.
Research demonstrates ACT as an evidence-based practice, with benefits including:
– Reduced hospitalizations up to 40%
– Increased housing stability
– Improved psychiatric symptoms
– Higher treatment adherence
– Enhanced vocational outcomes
– Lower treatment costs
The assertive, coordinated support provided by ACT facilitates recovery and prevents rehospitalization. ACT is now nationally recognized as a critical component of the continuum of care for those with the most severe mental illnesses.
Peer Support Services
Peer support involves services provided by individuals who have personal experience recovering from mental illness themselves. Peer support specialists engage in activities like:
– Sharing their recovery stories
– Serving as role models and providing encouragement
– Assisting with developing coping strategies
– Helping newly diagnosed individuals navigate the treatment system
– Co-leading group therapy and psychoeducational sessions
– Promoting engagement with treatment and recovery goals
Controlled studies show peer support services provide benefits such as:
– Reduced inpatient utilization
– Fewer crisis events
– Increased empowerment and quality of life
– Higher treatment satisfaction
– Improved self-care and social functioning
Peer support represents a key element of the recovery model for mental health treatment. Peers’ unique insights help instill hope and empower those struggling with severe mental illness.
Supported Employment
Unemployment rates among those with schizophrenia often exceed 90%. Many traditional vocational rehabilitation programs have strict eligibility criteria that exclude people with psychotic disorders.
Supported employment programs aim to help those with mental illnesses find and sustain competitive jobs in mainstream work settings. Core features include:
– Rapid job search based on patient preferences
– On-the-job support from employment specialists
– Integrated with mental health treatment teams
– Open to anyone regardless of diagnosis or background
– Jobs pays at least minimum wage in community settings
Dozens of high-quality studies demonstrate supported employment helps patients with severe mental illness achieve competitive employment. Success rates often reach 50-60% compared to 10-20% with traditional prevocational approaches. Supported employment is now regarded as an evidence-based practice and covered by Medicaid in many states. It represents a crucial component in recovery-oriented systems of care.
Pharmacogenomic Testing
Pharmacogenomics involves testing for genetic variants that influence drug metabolism and response. Genetic differences contribute to variable treatment effects and side effects between individuals. Pharmacogenomic testing for antipsychotics analyzes genes like:
– CYP2D6 – affects drug activation and clearance
– HTR2C – associated with metabolic side effects
– DRD2 – related to antipsychotic response and EPS risk
Based on an individual’s genetic profile, pharmacogenomic testing can provide guidance on:
– Metabolizer status (normal, rapid, poor) to inform optimal dosing
– Relative risks of weight gain, QT prolongation, EPS, hyperprolactinemia
– Likelihood of response to specific antipsychotic medications
Although not yet in routine use, pharmacogenomics represents a promising future approach for more personalized, tailored psychopharmacology. Early studies suggest pharmacogenetic testing could improve clinical outcomes, reduce side effects, and promote more efficient medication selection.
Neurostimulation Treatments
Neurostimulation techniques like electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS) are sometimes used as last-line or adjunctive treatments for schizophrenia.
– ECT – involves delivery of electrical current to the brain under anesthesia to induce a seizure. ECT appears effective for acute psychotic exacerbations unresponsive to medications.
– rTMS – uses magnetic fields to stimulate brain regions associated with regulating mood and psychosis. Small studies show rTMS applied to the dorsolateral prefrontal cortex may improve auditory hallucinations and negative symptoms.
– tDCS – transcranial direct current stimulation uses constant, low-voltage current to modulate cortical excitability. tDCS targeting the left dorsolateral prefrontal cortex has resulted in mild improvements in cognitive deficits and auditory hallucinations.
While not first-line treatments, neurostimulation techniques provide options for severe, treatment-resistant schizophrenia symptoms. However, more research is needed to refine methods and demonstrate definitive long-term benefits.
Novel Drug Targets
Most current antipsychotic medications work primarily by blocking dopamine receptors. While helpful for positive symptoms, dopamine antagonism does little for negative and cognitive symptoms. Researchers are now investigating drugs acting on novel molecular targets with hopes of better efficacy across all symptom domains.
Some emerging drug targets include:
– Metabotropic glutamate receptors (mGluR2/3 agonists)
– Alpha-7 nicotinic acetylcholine receptors (alpha-7 nAChR agonists)
– Glycine transporters (GlyT1 inhibitors)
– Serotonin 5-HT1A receptors (F15599, tandospirone)
– Phosphodiesterase 10A enzyme (PDE10A inhibitors)
– Neurokinin-3 receptors (NK3R antagonists)
Medications modulating these new systems remain investigational. While some failed late-stage clinical trials, others like mGluR2/3 agonists continue in active development. More research is needed to determine if these novel mechanisms can translate into clinical improvement beyond current treatments. But they represent promising avenues for developing medications that better address negative symptoms and cognitive deficits.
Summary
In summary, while there is still no cure for schizophrenia, ongoing research is leading to newer medical and psychosocial interventions that improve outcomes and quality of life for those affected by this serious mental illness. Recent advances include:
– Newer second-generation antipsychotic medications with improved side effect profiles
– Long-acting injectable formulations to promote adherence
– Early intervention programs soon after initial psychosis
– Cognitive remediation techniques to strengthen neurocognitive skills
– CBT and family therapy to manage symptoms and enhance functioning
– Supportive housing and ACT teams to prevent hospitalization
– Peer support and supported employment to facilitate recovery
– Pharmacogenomic testing to guide more personalized medication choices
– Investigational treatments like neurostimulation and novel drug targets
Continued progress combating this debilitating psychiatric disorder will rely on sustained research efforts to translate discoveries into more effective and personalized treatments. But the innovations of the past decade provide hope that the outlook for those diagnosed with schizophrenia may continue to improve in the years ahead.