The American Psychiatric Association’s Practice Guidelines and the Society of Clinical Psychology suggest the following for treatment of schizophrenia in adults:
First Line Treatments
Pharmacological Treatments – Antipsychotic Medications
A word about antipsychotic medications (from uptodate.com): These medications are commonly grouped into two categories, with “second-generation” (or “atypical”) applied to clozapine all antipsychotics first marketed after clozapine was approved in 1989, and “first-generation” applied to antipsychotics marketed previously. Recent clinical research, however, has strongly suggested that the distinction between first- and second-generation antipsychotics has questionable validity and is confusing. The pharmacologic properties, therapeutic effects, and adverse effects are not distinct between and are heterogeneous within the groups. Nevertheless, the terms first- and second-generation antipsychotic are still in widespread use. A valid distinction is that the newer (second-generation) antipsychotics tend to cause fewer extrapyramidal side effects than the older ones, particularly at the high end of approved dosage ranges.
- Second Generation Antipsychotic medications
- First Generation Antipsychotic medications
- Longer acting injectable versions of antipsychotic medications described above can be helpful with patients who have recurrent relapses or nonadherence to oral medications
Behavioral and Psychosocial Treatments
- Social Skills Training: Uses the principles of behavior therapy to teach communication skills, assertiveness skills, and other skills related to disease management and independent living.
- Cognitive Behavioral Therapy: This treatment involves cognitive restructuring, behavioral experiments / reality testing, self-monitoring and coping skills training, with an emphasis on a non-confrontational style and on normalizing psychotic experiences as part of a continuum with non-psychotic experiences. CBT for schizophrenia can focus specifically on psychotic symptoms (i.e. hallucinations or delusional beliefs) but has also been shown to be helpful for addressing depression and / or anxiety associated with psychotic symptoms and their impact on the person’s life.
- Assertive Community Treatment: A multidisciplinary team approach to intensive case management involving a high frequency of patient contact (typically at least once a week), low patient to staff ratios, and community outreach, allowing integration of medication management, rehabilitation, and social services as well as individualization to patients.
- Family Psychoeducation and Support: Because families can have a significant impact on their affected relative’s recovery and functioning, this treatment helps reduce the distress associated with caring for a family member’s illness, improving patient-family relations and communications, assisting with crisis intervention, problem-solving training, and relapse prevention.
- Supported Employment: An approach to vocational rehabilitation for individuals with serious mental illness that emphasizes integration of employment and mental health services, rapid community employment, individualized job development, and ongoing job support.
- Cognitive Remediation: These interventions are designed to improve cognitive function through repeated practice of cognitive tasks and / or strategy training, taking into account the motivational and emotional deficits that are often present in schizophrenia.
Second Line Treatments
In cases of nonresponse the above treatments, adjunctive treatments to be used in conjunction with antipsychotic medications with reasonable evidence of efficacy include:
- Beta-blockers (hostility, aggression)
- Mood stabilizers (mood instability, aggression)
- Antidepressants (depression, negative symptoms) – may exacerbate psychotic symptoms
- Benzodiazepines (anxiety, agitation, insomnia, akathisia)
Behavioral and Psychosocial Treatments
- Acceptance and Commitment Therapy: This treatment aims to change the relationship individuals have with their own thoughts, feelings, memories, and physical sensations that are feared or avoided. Acceptance and mindfulness strategies are used to teach patients to decrease avoidance, attachment to cognitions, and increase focus on the present.
- Cognitive Adaptation Training: This treatment teaches the individual with schizophrenia to use strategies that compensate for (or work around) the cognitive deficits associated with schizophrenia.
- Illness Management and Recovery: This treatment emphasizes recovery by helping clients set and pursue personally meaningful goals. IMR combines 1) psychoeducation about mental illness, 2) cognitive-behavioral approaches to medication management, 3) planning for relapse prevention, 4) social skills training to strengthen social support, and 5) coping skills to manage symptoms of mental illness.
Additional Treatments to Consider
Preliminary evidence suggests that the following strategies, while not a substitute for better validated treatments described above, might be considered.
- Electroconvulsive Therapy (ECT)
- Omega-3 Fatty Acid Supplements