DESPITE significant advances in the field of psychiatry, there remains substantial misconception regarding psychiatric illnesses and their treatment. Most of these misconceptions stem from a lack of knowledge about available treatment options.

SCHIZOPHRENIA

Schizophrenia is one of the more common mental disorders affecting the Jamaican population. It is characterised by strange or disorganised behaviour and may result in the person talking to self, hearing voices when no one is there, or seeing things no one else can see.

Patients with schizophrenia also display bizarre beliefs, which may range from believing that people are trying to harm them to aliens attempting to abduct them. They may also neglect personal hygiene and act in a verbally or physically aggressive manner. It is important to recognise that not all patients will exhibit all the symptoms and signs of the illness; it is mainly diagnosed based on a clinician taking a thorough history and ruling out other medical conditions.

Schizophrenia cannot be diagnosed until and unless all medical conditions such as brain infections and cancer, which may cause similar symptoms, are ruled out. Also, the symptoms cannot be attributed to an underlying drug or another medication. The presentation also has to last for a minimum period of six months before it can be classified as schizophrenia.

WHO IS AFFECTED

This debilitating illness affects youth who are in their prime and causes a significant economic and emotional burden on the patient and family alike. Many theories have been put forth to explain the development of this illness and the majority agree on a genetic predisposition, complications during prenatal development in the womb, and early onset stress and trauma.

Despite many treatment options now available, non-compliance is high. The reasons for non-compliance vary, some of which are the fear of taking medication, stigma and ignorance about treatment options.

TREATMENT OF SCHIZOPHRENIA

Here, I have made an attempt to simplify the biological treatment of this condition.

Schizophrenia affects the brain mostly at the microscopic level. It is due to an imbalance in chemicals, also known as neurotransmitters, in different areas of the brain. The changes that the brain undergoes are not always visible with the naked eye or through radiological investigations such as computed tomography scans. Schizophrenia, thus far, can only be diagnosed based on signs and symptoms.

Treatment of schizophrenia is done from a biopsychosocial perspective, meaning pharmaceutical treatment, psychotherapy and social skills training.

Antipsychotic medication — which is generally classified into two types, namely typical and atypical — is the mainstay of biological treatment for schizophrenia.

The typical antipsychotics are first generation and have been around since the 1950s when they were first discovered. The primary complaint patients have about this class is drowsiness, being “stiff”, “walking like a zombie”, and “drooling”. This is because these agents cause what is known as movement disorders.

However, these side effects are dose related and many patients develop tolerance to them over the course of a few weeks. If the side effects are intolerable, patients may be tried with the other class of medications known as atypical antipsychotics. These agents cause significantly less to no movement disorders and are generally better tolerated.

Atypical antipsychotics do have their own set of side effects, however, one of which is known as the ‘metabolic syndrome’. This is a fancy term for increased blood glucose, increased weight gain and increased lipids or cholesterol.

Certain medications of this class also have their own unique set of side effects, for example: gynaecomastia, which is a common condition that causes boys’ and men’s breasts to swell and become larger than normal, with the medication Risperidone; and agranulocytosis, a condition in which the bone marrow does not make enough of a certain type of mature white blood cells, with the medication Clozapine. It should be noted that the prevalence of these side effects is not as high as people make it out to be.

MANAGING NON-COMPLIANT PATIENTS

Patients who are non-compliant with oral tablets are generally managed with two strategies. One strategy is long-acting depot injections, similar to depo-provera injections for contraception, which can be injected intramuscularly to treat symptoms and maintain blood levels of medication. These injections are the equivalent of the oral tablets, however, in injectable formulations

They stay in the system between two to four weeks depending on the specific agent.

The next strategy is oral dispersible tablets or liquid formulations of antipsychotics. These can be easier to administer and quickly dissolve in the patient’s mouth preventing them from spitting out the medication.

Bottom line is that there is no difference in efficacy between the typical and atypical medications and both of them work equally well. Also, all medications taken for any illness have side effects, however in my opinion, psychotropic medication side effects are unfairly stressed in the general setting.

The refusal or lack of treatment of mental disorders can result in a debilitated patient and breaking of the family dynamics. Knowledge of treatment options available is crucial.

Dr Ashish Sarangi MBBS is a resident psychiatrist at the University Hospital of the West Indies. He may be contacted via email at aks_sarangi@hotmail.com