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Schizophrenia

By Greg L. Carter, MB.BS, FRANZCP, Cert Child Psych, Ph.D., Conjoint Professor and Principal Researcher, Centre for Brain and Mental Health Research, University of Newcastle, NSW. Australia

The incorrect idea that Schizophrenia has a universally poor prognosis may be widely held. Unfortunately, this belief may limit the development of clinical and research opportunities to try to improve the current situation and to restore some hope to clinicians, patients and their families. 

I first became aware of the notion of stages of illness in schizophrenia and the idea that the prognosis was not universally poor when I read the work of Luc Ciompi. His research suggested that there were three stages:  a beginning phase (that might now call the prodromal phase characterised by non-psychotic symptoms), an evolutionary phase, (that might now be called the acute psychotic phase, characterised by positive symptoms), and the end-state (that might now be called a chronic negative symptom phase). He also demonstrated that progression through these stages was not uniform, that the severity and recurrence of symptoms in all stages was variable, and that a substantial minority of people had a good prognosis [1; 2].

Thomas Insel from the NIMH in Bethesda Maryland was asked to look into the future and imagine how we might deal with Schizophrenia in the year 2030. His thoughts were published in the journal Nature. “Schizophrenia today is a chronic, frequently disabling mental disorder that affects about one per cent of the world’s population. After a century of studying schizophrenia, the cause of the disorder remains unknown. Treatments, especially pharmacological treatments, have been in wide use for nearly half a century, yet there is little evidence that these treatments have substantially improved outcomes for most people with schizophrenia. These current unsatisfactory outcomes may change as we approach schizophrenia as a neurodevelopmental disorder with psychosis as a late, potentially preventable stage of the illness. This ‘rethinking’ of schizophrenia as a neurodevelopmental disorder, which is profoundly different from the way we have seen this illness for the past century, yields new hope for prevention and cure over the next two decades.” In this important paper Insel emphasised the need for an improved understanding of the stages of the illness and the progression of symptoms and the importance of the development of new treatment paradigms that focus on early intervention; commencing psycho-social and pharmacological treatment at the stage of prodromal  symptoms or even in people with high risk for schizophrenia before any symptoms have developed [3]. Patrick McGorry from Melbourne Australia has pioneered the development of early intervention in Schizophrenia and an emerging body of research work has begun to demonstrate the benefits of this approach [4].

The incidence rates for Schizophrenia are higher for males than females, around 1.4 times higher [5]. All-cause mortality rates are elevated in Schizophrenia and death by suicide remains an important negative outcome; with the risk of death by suicide in both males and females greater than the general population. At the population or public health level it is important to recognise that although Schizophrenia carries a similar relative risk for suicide as does Depression and Drug and Alcohol dependence, the population attributable risk is much lower because the prevalence of Schizophrenia is much less. In effect, if all cases of Schizophrenia could be removed from the population by prevention or treatment, this would only remove around 7% of all suicide deaths [6].

Perhaps one of the best ways to reduce the impact of suicide in Schizophrenia would be to reduce the incidence of Schizophrenia itself. Alan Brown from Columbia University, New York, has demonstrated that removing all exposure to maternal influenza, toxoplasmosis, and genital/reproductive infections, might reduce the incidence of Schizophrenia by around 30% [7].

The next level of approach would be to reduce exposure to risk factors for suicide in Schizophrenia. Keith Hawton from Oxford England, conducted a meta-analysis of suitable studies published before 2005 [8]. Kahyee Hor and Mark Taylor from Edinburgh Scotland completed a meta-analysis on suitable studies published since 2005. The lifetime risk of suicide was approximately 5% in Schizophrenia. Risk factors for later suicide were being young, male, with a high level of education, prior suicide attempts, depressive symptoms, active hallucinations and delusions, and the presence of insight. A family history of suicide, and comorbid substance misuse were also associated with later suicide. The only consistent protective factor for suicide was delivery of and adherence to effective treatment. They concluded that prevention of suicide in schizophrenia will rely on identifying those individuals at risk, and treating comorbid depression and substance misuse, as well as providing best available treatment for psychotic symptoms [9]. 

Overall, the goal of reducing suicide in schizophrenia might be best achieved by integration of prevention and treatment interventions aimed at reducing the incidence of schizophrenia, early intervention for those at risk of schizophrenia and good treatment programs that address depression, substance misuse as well as optimal treatment for schizophrenia symptoms. Treatment programs should not be restricted to only pharmacological interventions.

The challenge for the present is to work out how to best use the knowledge we already have. To make changes to the “system” means that changes need to be made not just in clinical and prevention services, but also in education, funding, administrative and political spheres so that we can start the progress to the situation imagined for 2030 by Thomas Insel. 

References

1. Ciompi L. 1984. Is there really a schizophrenia? The long-term course of psychotic phenomena. The British Journal of Psychiatry 145:636-640.

2.  Ciompi L. 1980. The natural history of schizophrenia in the long term. The British Journal of Psychiatry 136:413-420.

3. Insel TR. 2010. Rethinking schizophrenia. Nature 468:187-193.

4.  McGorry P, Johanessen JO, Lewis S, Birchwood M, Malla A, Nordentoft M, Addington J, Yung A. 2010. Early intervention in psychosis: keeping faith with evidence-based health care. Psychological Medicine 40:399-404.

5. McGrath JJ. 2005. Myths and plain truths about schizophrenia epidemiology - the NAPE lecture 2004. Acta Psychiatrica Scandinavica 111:4-11.

6. Li Z, Page A, Martin G, Taylor R. Attributable risk of psychiatric and socio-economic factors for suicide from individual-level, population-based studies: A systematic review. Social Science & Medicine In Press, Corrected Proof.

7.  Brown AS, Patterson PH. 2011. Maternal Infection and Schizophrenia: Implications for Prevention. Schizophrenia Bulletin 37:284-290.

8. Hawton K, Sutton L, Haw C, Sinclair J, Deeks JJ. 2005. Schizophrenia and suicide: systematic review of risk factors. The British Journal of Psychiatry 187:9-20.

9. Hor K, Taylor M. 2010. Review: Suicide and schizophrenia: a systematic review of rates and risk factors. Journal of Psychopharmacology 24:81-90.

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