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Drug therapy is supported by the Dopamine Hypothesis and lends support to
the biological explanation of schizophrenia. All antipsychotics
affect neurotransmitters in the brain to bring about changes in symptoms. (When an
idea is backed up by a well-researched scientific theory, it has construct validity) Use
a study from DA hypothesis evaluation for this point.
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An alternative treatment is cognitive behavioural therapy (CBT)
CBT used to be considered inappropriate for schizophrenia because cognitive
therapy involves talking and thinking clearly - exactly what schizophrenia interferes
with. However, Bradshaw (1998) challenged this with a case study that showed a
patient (Carol) benefiting from CBT.
However, in the long term, CBT might be more beneficial. Bradshaw (1998) found
that Carol (the patient from the case study) showed that the benefits of CBT were
still there a year after the therapy ended. Whereas, the longer someone takes
antipsychotics, the more likely severe side-effects will develop and, if they stop
taking the drugs, their symptoms will return.
Both treatments take time to be effective: drug therapy takes days-to-weeks,
cognitive therapy takes months. This means a patient who is very distressed and
perhaps suicidal will get much more help in the short term from antipsychotics.
Kingdon and Turkington (1994) suggest that, in combination with anti-psychotic
drugs, CBT can reduce delusions and disturbing hallucinations (through reality
testing). An "integrated approach" involves combining the two treatments. It may be
possible to reduce the dependency on antipsychotics as the cognitive therapy takes
effect.
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All the drugs used to treat schizophrenia have adverse reactions; these could include
weight gain, tremors and drowsiness. Some people feel the side-effects are worse
than the symptoms they are alleviating. Lieberman et al. (2005) A total of 1493
patients with schizophrenia were recruited at 57 U.S. sites and randomly assigned to
four different groups (a different drug was used in each group) It was found that, 74
percent of patients discontinued the study medication before 18 months.
Discontinuation was due to intolerable side effects. This has serious consequences
for the effectiveness of the treatment.
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Some critics argue that antipsychotics are a "placebo" - they only work because the
patient believes they will work. This was tested by Meltzer et al. (2004) who used a
sample of 481 patients with schizophrenia. The patients were put in 3 conditions: (1)
patients receiving one of four new trial drugs; (2) patients receiving a typical
antipsychotic (haloperidol); (3) patients receiving a placebo (a pill that looked like an
antipsychotic but had no effect). After 6 weeks, patients taking haloperidol and two
of the trial drugs had reduced symptoms. Haloperidol gave significant improvements
in all aspects of functioning. Patients taking the placebo and two of the other trial
drugs were still the same. This shows that antipsychotics do reduce symptoms.
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McEvoy et al. (2006) compared switching to clozapine with switching to another
atypical antipsychotic in patients who had discontinued treatment with a newer
atypical antipsychotic. They found that of the four drugs that were offered to the
patient group to try, the most effective was clozapine because patients in this group
continued taking this drug significantly longer than any of the others.The assessment
of symtoms taken after three months of taking the new drug also showed the most
improvement in the group taking clozapine. Clozapine has fewer side effects which
may explain this result. (it is important to remember that patients must have a blood
test every 2 weeks due to white blood counts – close monitoring is required)
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Harlow et al. (2012) carried out a 20-year longitudinal study and found that patients
who did not take their medication had fewer psychotic episodes than those who
did.
Harlow et al (2012) : All of the patients were treated conventionally in the hospital,
and then Harrow followed them as their lives unfolded, periodically assessing how
well they were doing (longitudinal study). At the end of 15 years, he had successfully
followed 145 of the 200 patients enrolled into the study, and at the end of 20 years,
he had outcomes data for 139 patients.
35% of the SZ group were off antipsychotics, and that percentage remained fairly
stable. There was no significant differences in severity of psychotic symptoms
between the on-med and off-med groups at two years, but starting with the 4.5-year
followup and continuing through year 20, those “who were not on antipsychotic
medications were significantly less psychotic than those on antipsychotics.”
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Drug therapy doesn't work for everyone. Although more patients respond to the
atypical drugs than to the first generation antipsychotics, this is still not all
patients.
Fleischhacker (1995)
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“Although conventional neuroleptic drugs are effective for alleviating positive
symptoms of schizophrenia, and preventing their recurrence in many patients, they
have serious limitations. Approximately 30% of patients with acutely exacerbated
psychotic symptoms have little or no response to conventional antipsychotics, and
up to 50% of patients have only partial response to medication. Negative symptoms,
mood symptoms, and cognitive deficits are marginally responsive to conventional
neuroleptics. In particular, primary negative symptoms are very resistant to the
typical drugs.”
Complying with medication leads to a reduced risk of hospitalisation. Weiden et al.
(2004) This was a retrospective review of California Medicaid pharmacy refill and
medical claims for 4,325 outpatients for whom antipsychotics were prescribed for
treatment of schizophrenia from 1999 to 2001. They found that risk of
hospitalization was significantly correlated with compliance. Lower compliance to
medication was associated with a greater risk of hospitalization.
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Not a ‘cure’ so relapse is likely when medication is stopped. Sampath et al (1992)
found that 75% of those transferred to a placebo drug after a course of antipsychotic
medication relapsed within one year (compared to 33% of a control group).
Reductionism. Drug therapy only focuses on a biological cause and does not take
into account a psychological approach to treatment. The biological treatments are
designed to alter brain structure or chemistry only. This ignores the influence of
psychological factors, such as social class or adversity, which do not lend themselves
to a medical intervention. Recent therapies, such as family therapy, recognise the
importance of communication and relationships within the family. It focuses on
wider social support, emotional factors, communication, and family support (less
reductionist treatment). Or perhaps an interactionist approach is necessary –
medication and therapy? Refer to point 6 regarding CBT).