Treatment and management of schizophrenia

D. G. Cunningham Owens and E. C. Johnstone

Introduction Evidence .forefficacy

Drugjre,atm,e,,n,t 'Positive: features 'Negativelfsalures

Cognitive performance

Non.-sp.ecific..symptomatolpgy

Behaviour Maintenance Treatment resistance Psychosocial interventions

Psychodynami.c.. psychotherapy

Social, .skillsJ.rain.ina .and Mil,lnMe,ss..self-m,an,a.gemeot, .programmes

Familyinterventions

Coqnitive-behavipu^raljherapy

AlteinativesJohospitalization

Principles. pftreatmentand. management Preliminaries

|dentifyi.nlgMao,als..andM.defini.nlgMstructu1re

TheiMacuteMphase

Low-£o,tencyM.regimens ,High.-p,ote,n,c,y. „regimens

ThelMppst-acuteMPlhase

TheMmaintenance.. phase Psychiatric emergencies ppPLresponsenandM.tlreatmenlt. resistance

Antipsychotics

.FJ.rst.-lln,e.„a.diu.n.c.tlvs.Mm,edlcatio!n.? Second-lineadiunctiyetreatments

Psychosocial .interventions.. in .management Concluding.Mremarks

Chapter. References Introduction

Historically, therapeutic interventions in patients with psychotic disorders were largely palliative and predicated on essentially psychosocial principles, (1) although the administration of medicines and other physical techniques has been recommended since antiquity (2) and actively employed in Britain for some 300 years.(3)

Over the last 50 to 60 years, a number of physical treatments of schizophrenia have aimed at promoting more specific benefits. Insulin coma, electroconvulsive therapy (ECT), and prefrontal leucotomy(4) became widely applied on the basis of enthusiasm rather than scientific study, but since the development of safe and effective medications they have largely fallen into disuse. Since chlorpromazine was introduced in 1952 and shown to have specific antipsychotic properties, (5) numerous antipsychotic agents have come into use, which, along with a range of psychosocial interventions, have been favourably evaluated.

There remains an obvious discrepancy between the generally favourable results of, especially drug, trials in this field and an on-going concern about the difficulties posed by schizophrenia. Some of this can be explained by the difference between responses evident in clinical trials (efficacy) and those that pertain in ordinary circumstances (effectiveness). The unique conditions of the controlled trial provide essential information on which to base rational therapeutic decisions, but not necessarily information that translates to all clinical contexts.

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