Schizophrenia occurs in about 1% of the people in every community worldwide. It is probably the most severe and potentially disabling form of mental illness.

Schizophrenia may present as an acute or chronic illness. Features are:

• Characteristic ‘positive’ or ‘negative’ symptoms
• Deterioration in social, work or interpersonal relationships
• Continuous signs of disturbance for at least 6 months

Psychosis associated with substance abuse and mood disorders with psychotic features may mimic schizophrenia. The clinical findings are many and can change over time.

SYMPTOMS

‘Positive’ symptoms:

• Hallucinations
• Delusions
• Incoherent speech or illogicality
• Odd or disorganised behaviour
• Disorders of thought possession

‘Negative’ symptoms include:

• Poverty of speech or of content of speech
• Apathy
• Reduced social contact
• Flattened affect (showing little facial expressive responses)

Delusions may be persecutory (undue suspicion) or totally bizarre like being controlled or being made to feel emotions or sensations.

Hallucinations - may involve any of the senses but auditory ones are most common; experienced as voices speaking clearly or in mumbled tones.

Disorders of thought possession include feeling of the patient’s thoughts being accessible to others. Motor disorders often occur but are not essential for diagnosis

TREATMENT

Treatment of schizophrenia is probably best left to the psychiatrist though treatment for acute episodes can be started and follow up treatment continued by most health care givers.

Therapeutic objectives

• To abolish symptoms and restore functioning to the maximum level possible
• To reduce the chances of recurrence

Non-Pharmacological Treatment

• Supportive psychotherapy
• Rehabilitation

Pharmacological Treatment

(Evidence rating: A)

Antipsychotic drugs are the mainstay of treatment.

Recommended antipsychotics:

• In acute attack, give:

Chlorpromazine, IM, 100-150 mg 6-8hourly

• Maintenace, give:

Chlorpromazine, oral, 100-600 mg daily in divided doses not exceeding 200 mg per dose

• Haloperidol, oral, 5-20 mg daily or

• Trifluoperazine, oral, 10-30 mg daily or

• Depot antipsychotics e.g. Fluphenazine Decanoate, IM, 25 mg monthly for recurrent and chronic patients

• Risperidone, oral, 2-6 mg in 2 divided doses or single daily dose

Adjunct treatment

Antiparkinsonian drugs should only be used if reactions occur or at higher doses of antipsychotics likely to cause reactions. Any of the following could be given.

• Trihexyphenidyl (Benzhexol), oral, 5 mg one to 3 times daily
• Biperidine, oral, 2 mg one to 3 times daily
• Biperidine, IV, 2 mg SLOWLY 2-4 minutes for acute dystonic reactions.

In the absence of these antiparkinsonian drugs Promethazine, oral or IM, 25-50 mg or Chlorphenamine (Chlorpheniramine), oral, 4-8 mg or

Diazepam, oral or IV, 5-10 mg may be used as a substitute.

Duration of Treatment

A clearly diagnosed schizophrenic patient must be on medication for at least 18 months after remission of symptoms for a first episode.

After two or more episodes especially if they follow within a year or two of each other - treatment should probably continue for life although ‘drug holidays’ may be discussed from time to time.

REFER

Since a diagnosis of schizophrenia carries probable life long implications and treatment may be of life long duration:

• Refer after treatment of acute episode

• Refer recurrent cases

• Refer patients who cannot be controlled with drugs and may require Electroconvulsive Therapy.