Schizophrenia
New drugs, new promise

By Don Vaughan
November 15, 2004

Mysterious, misunderstood, misdiagnosed — schizophrenia has been all of these. Worse, treatment of the mental disorder has long been a challenge for both patients and health care providers because of the often severe adverse effects of the drugs developed to control it. For example, thorazine, though a popular and effective antipsychotic, was known to cause tardive dyskinesia and other reactions so debilitating that many schizophrenic patients opted to stop treatment rather than try to deal with them.

In recent years, a new class of drugs has become available for the treatment of schizophrenia. Known collectively as “atypicals,” these drugs have shown success in regulating the neurotransmitters that are believed to be at the core of schizophrenic behavior. As a result, atypicals have become the first line of treatment in the management of schizophrenia, says Noreen Brady, RN, PhD, assistant professor and director, Sarah Cole Hirsh Institute, Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland.

Much is known about schizophrenia, and yet much more remains a mystery.

“Schizophrenia is difficult to define, but the definition that, to me, makes the most sense is schizophrenia is a condition or disease denoting a persistent mental illness affecting behavior, thinking, and emotion,” Brady says. “Schizophrenia is a thought disorder whereas depression and bipolar illness are mood disorders. It’s the thought component of [schizophrenia] that often leads to characteristic behaviors other people see as bizarre or frightening.”

Schizophrenia affects about 2.2 million American adults and 1.1% of the world’s population, according to the National Institute of Mental Health. By comparison, The 2004 Diagnostic and Statistical Manual of Mental Disorders (DSM IV) puts the lifetime incidence of clinical depression at 7% to 25% of the nation’s population; anxiety disorders, it says, are even more common.

Although schizophrenia is not characterized as one of the more common psychiatric illnesses, it can be one of the most severe. It typically first presents when a patient is in his or her early to mid-20s, although earlier or later onset is possible, says Paula Steates, RN, BSN, a staff nurse on the psychiatric unit at the Medical College of Georgia in Augusta.

“A patient’s first break is often triggered by something emotionally stressful, such as going away to college,” Steates says. “We often hear stories of the roommate who became increasingly weird, started hearing voices, and became very paranoid. That’s typical of schizophrenia.”

Diagnosed using the DSM IV, schizophrenia is often divided into subsets: paranoid schizophrenia, catatonic schizophrenia, residual schizophrenia, and undifferentiated schizophrenia, according to Ellen Mahoney, RN, DNSc, clinical assistant professor, School of Nursing, The Catholic University of America in Washington, D.C.

The prognosis for schizophrenia has long been viewed as a percentage game, Mahoney says. Studies have shown that about 10% of patients with schizophrenia will take their own lives regardless of treatment. Of the remaining 90%, it’s commonly believed one-third will have very good prognoses, one-third will have ups and downs, and one-third will experience a lifelong downward spiral.

“I believe there’s something to that [breakdown], but this is a tricky population to figure out,” Mahoney says. “If you ask nurses or other health professionals who are in the trenches what the outcome is for schizophrenia, without thinking they might say it’s lousy because these workers are in systems that see only people who are intermittently doing poorly or are on a downward course. They never see the people who are doing very well.”

According to Brady, treatment of schizophrenia is gradually moving from maintenance to more of a recovery model.

“In the past, patients with schizophrenia were not expected to recover, and if any of them did, it was obviously a misdiagnosis,” she says. “We’re much more optimistic now with the new medications.”

Atypicals find common use

The most commonly prescribed atypical antipsychotics today include aripiprazole (Abilify), ziprasidone (Geodon), risperidone (Risperdal), quetiapine (Seroquel), and olanzapine (Zyprexa), report the psychiatric nurses interviewed for this article. Clozapine (Clozaril) also is an atypical antipsychotic but has been relegated to a treatment of last resort by some providers because of its long list of potentially serious side effects, including anticholinergic toxicity, agranulocytosis, seizures, and myocarditis. In most cases, clozapine is generally prescribed only for patients who fail to respond to anything else, Brady says.

Other providers, such as Gayle Johnson Bohrer, RN, MSN, a clinical nurse specialist and lecturer at the school of nursing at the University of Northern Colorado in Greeley, report positive outcomes with clozapine when its use is vigilantly monitored.

“Clozapine was the first atypical and is still a standard by which the other [drugs] are measured,” Bohrer says. “It’s sometimes portrayed in a negative light, often by those who have limited experience with the drug. Obviously, providers are going to try the other atypicals first because not as much monitoring is needed with those drugs. But I’ve seen clozapine work for many clients where nothing else has.”

Atypical antipsychotics help control the symptoms of schizophrenia by adhering to specific receptors in the brain and regulating levels of key neurotransmitters, according to Brady.

“Schizophrenia is a neurochemical-type disorder characterized by imbalances of dopamine, serotonin, and other neurotransmitters,” she says. “The atypicals try to balance and reregulate them.”

One of the greatest benefits of the new atypicals: They cause fewer of the debilitating adverse effects that made the previous generation of antipsychotics such a mixed bag for patients and providers alike. However, the atypicals are not without potential adverse effects of their own, including weight gain, type-2 diabetes, a prolonged QT interval, and even sudden death, Steates says.

“Treatment varies according to the individual. The most important thing is finding a medication the patient likes; otherwise, the patient probably is not going to take it,” Steates says. “We’re constantly assessing that, asking patients, ‘How is your medicine working?’ Very often they’re extremely pleased when we switch them from one of the older drugs like Haldol to one of the newer atypicals. They’ll say, ‘I love my medicine! It’s great!’”

Nurses and others can help patients with schizophrenia achieve optimum benefit from their medications by aggressively addressing the drugs’ potential adverse effects, Mahoney says.

“Both patients and providers are challenged to think about early interventions to prevent some of these side effects or the exaggeration of these side effects,” she says. “If you know, for example, that a certain percentage of patients on Zyprexa gain weight, then I think one of your interventions should be about preventing weight gain, either through an exercise program, setting up meal planning with patients, or by some other means. We have to be proactive with these patients. A lot of nurses are already doing that, but not all.”

Advantage: Nurses

Successful treatment of schizophrenia requires a multidisciplinary approach that includes psychologists, psychiatrists, nurses, and social workers. Nurses are often responsible for ensuring patients remain on the right medications and take those medications as prescribed – but they bring much more to the table than that, Steates says.

“Nurses function as patient advocates,” she says. “In the mental health setting, we strive to establish a therapeutic rapport with patients, one that promotes healing by alleviating the stress the patient experiences. The nurse also functions as a liaison between the patient, physicians, and family members. Nurses are central to the multidisciplinary team. They contribute assessments and ensure patients’ needs are met in the acute care setting and follow-up care is in place.”

Brady agrees. “Nurses are experts at establishing and maintaining relationships with patients with schizophrenia and managing their inpatient milieu,” she says. “Doctors and residents come and go, but nurses are usually pretty stable. Nurses bring a wealth of experience and education. They truly are holistic. It’s not just the mental illness they see — it’s the whole person. I can’t imagine treating patients with schizophrenia without nurses.”

Don Vaughan is a freelance writer.