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Case Study: Schizophrenia and Work: Martin’s Story

Martin had been out of work for several years following a prolonged psychotic episode which began when he was studying at university. He desperately wanted to get into work but found that employers treated his prolonged absence “on the sick” with suspicion. He thought that if he could do a period of work experience that would show prospective employers that he was capable of working again but he was afraid that if he did it might affect his benefits.

So Martin made an appointment to see the Disability Employment Advisor at the Jobcentre to discuss his plans. She was understanding and helpful and explained that a work placement would not affect his benefits as long as it was done as part of the Jobcentre’s own scheme. She also told him that the scheme would pay his travel-to work expenses while he was on the placement.

Job-searching

Next Martin researched local employers using the internet and the local press, looking for companies that might have vacancies in the sort of clerical and administrative work he thought he could do. Then he called the companies by ‘phone and speaking to the person on the switchboard checked that he had the correct postal address for them and asked the name of the person in charge of recruiting. It is vital to be able to write to a named person rather than just the Human Resources Manager.

Martin had already spent a lot of time on his CV so now he compiled a covering letter to go with it. It took him about a month to work up his CV and covering letter using books that he got from the local library. He also managed to get advice from a local back-to-work scheme recommended by the Disability Employment Advisor at the Jobcentre. Martin knew that it was essential that his letter and CV had the maximum impact.

Martin sent his CV and letter off to six employers and then waited about a week before calling them up on the ‘phone. He asked to speak to the person he had written to but if the person on the switchboard asked the reason for his call he simply said that he was calling to follow up a letter he had written.

After approaching about 20 employers in this way he finally found one who said there could be an opening for work experience in a couple of months time. So over the next three months Martin kept in touch with the company by ‘phone once a month just to let them know that he was still keen on coming to work for them.

The interview

Finally the company asked him in for an interview. Before going to the interview Martin prepared really well in advance by researching the company well and trying to anticipate the sorts of questions he would be asked. He also went to the local library and took out some books on interview techniques and managed to get on a one day course on interview skills that the Jobcentre had told him about. This included a mock interview which he found particularly useful.

The day of the interview arrived and Martin was very nervous but he was up early and washed and dressed. To be sure of being on time he left an hour early and checked out the location of the office. Then he went to Starbucks for a coffee while he waited. This gave him an opportunity to flick through his notes and prepare on some of the answers he had been working on. He made sure that he was punctual and well groomed and did his best to present himself well at the interview.

Despite being really well prepared walking through the front door of the office was one of the hardest things that he had done for years. But the receptionist was polite and could not have been more helpful. She made him feel welcome and even offered him a coffee (which he declined).

The Human Resources Manager who interviewed Martin was very professional but quickly put him at his ease. He asked questions about his education at school, his hobbies and pastimes and his qualifications and then came the bit that Martin had been dreading when the HR Manager asked him why he had dropped out of college. Martin explained that he had had a breakdown caused by too much stress while he was at college. He went on to explain that although it was a bad breakdown it was behind him now and that with the help of his family and friends and his doctor he had been able to make a really strong recovery. He also explained that in some ways the experience had made him a stronger person and that he had matured as a result of it.

As the end of the interview approached Martin was sure that he had flunked it but the interviewer told him that he had been successful and asked him to start on Monday. Martin was delighted to be offered a period of three months unpaid work experience during which he would work for two days a week at their local office doing clerical and administrative work.

Martin was walking on air when he left the office. All his hard work had been worth it.

The next day Martin called the Disability Employment Advisor at the local Jobcentre to tell them about the offer and see how his benefits would be affected. She confirmed that his benefits wouldn’t be affected as long as he only worked for 16 hours a week.

The placement

For the next three months Martin worked hard at his placement. He made sure that he got all the basics right: being punctual and well groomed every day. At work he was helpful and got on well with the other workers. Although he was very shy at first he soon learned the importance of making small talk with his colleagues and building good working relationships.

As the end of his placement approached Martin wondered if he would be offered a permanent position. He asked the HR Manager about this but sadly he was told that there were no permanent vacancies at that time so when the end of his placement came Martin had mixed feelings. On the one hand he was disappointed that the work experience had not turned into a permanent job but on the other hand he had had three months experience in the workplace and had something to put on his CV to demonstrate to other employers that he could work. And most importantly he had that all important reference from a well respected local employer.

But that isn’t quite the end of the story. Martin continued searching for a job without success for another six months but continued to keep in touch with the HR Manager he had worked for during his work experience. One day he saw in the local press that they were advertising for a clerical assistant so he called them and explained that he was still jobsearching and would be available for this position. The HR Manager was very pleased to hear from him and said that he would call him back. The next day Martin got a call asking him to go in for an interview straight away and was offered the job.

Martin called the Jobcentre Plus helpline and found out what benefits he would be entitled to while he was working and was pleased to find out that he would be better off in work.

Martin has now been employed in his new job for two years and is delighted to be living an independent lifestyle free of the benefits culture he was in before. It has had its difficulties though. For instance Martin found that his illness had left him emotionally very sensitive and that he found it difficult to cope if his work was criticised. But he knew that this was something he had to learn to live with and gradually he managed to learn new social skills that helped him to cope better and at the same time helped him in other areas of his life.

Martin has enjoyed the structure that the new job has brought to his life. He enjoys the work and the social contact that the job entails. He has made new friends and above all his self-esteem has grown vastly. Now when people ask him what he does for a living he no longer has to say that he is unemployed.

Some Key Points from Martin’s Story:

• Research the local job market really well
• Before writing to a firm call to check the postal address.
• Find out the name of the person in charge of recruitment. Writing to a named person makes sure your letter gets read.
• You can’t spend enough time preparing your CV and cover letter. Get as much help as you can from books, the library etc.
• When making follow up calls avoid Mondays and Fridays as these are busy days for people in business. Similarly don’t call too early in the morning or after 3.30 pm and don’t call around lunchtime.
• When making follow up calls be prepared for few false starts but use these to develop your technique. Treat the first half a dozen calls as practice calls.
• Don’t pester firms with too frequent follow up calls. Once every three weeks is about right.
• Be prepared for disappointment and don’t feel let down by it.
• Before going for an interview research the firm really well. Google and Google News and the local press are useful sources.
• It is perfectly normal to be nervous at an interview. Try to minimise the nerves by making sure you have planned and prepared well and getting a good night’s sleep beforehand.
• At the interview you may be asked about your illness. Be honest but there is no need to disclose your diagnosis at this stage unless you are asked directly: a broad brush explanation such as “a breakdown” is sufficient.

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Our Most Troubling Madness: Case Studies in Schizophrenia Across Cultures

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Module 11: Schizophrenia Spectrum and Other Psychotic Disorders

Case studies: schizophrenia spectrum disorders, learning objectives.

• Identify schizophrenia and psychotic disorders in case studies

Case Study: Bryant

Thirty-five-year-old Bryant was admitted to the hospital because of ritualistic behaviors, depression, and distrust. At the time of admission, prominent ritualistic behaviors and depression misled clinicians to diagnose Bryant with obsessive-compulsive disorder (OCD). Shortly after, psychotic symptoms such as disorganized thoughts and delusion of control were noticeable. He told the doctors he has not been receiving any treatment, was not on any substance or medication, and has been experiencing these symptoms for about two weeks. Throughout the course of his treatment, the doctors noticed that he developed a catatonic stupor and a respiratory infection, which was identified by respiratory symptoms, blood tests, and a chest X-ray. To treat the psychotic symptoms, catatonic stupor, and respiratory infection, risperidone, MECT, and ceftriaxone (antibiotic) were administered, and these therapies proved to be dramatically effective. [1]

Case Study: Shanta

Shanta, a 28-year-old female with no prior psychiatric hospitalizations, was sent to the local emergency room after her parents called 911; they were concerned that their daughter had become uncharacteristically irritable and paranoid. The family observed that she had stopped interacting with them and had been spending long periods of time alone in her bedroom. For over a month, she had not attended school at the local community college. Her parents finally made the decision to call the police when she started to threaten them with a knife, and the police took her to the local emergency room for a crisis evaluation.

Following the administration of the medication, she tried to escape from the emergency room, contending that the hospital staff was planning to kill her. She eventually slept and when she awoke, she told the crisis worker that she had been diagnosed with attention-deficit/hyperactive disorder (ADHD) a month ago. At the time of this ADHD diagnosis, she was started on 30 mg of a stimulant to be taken every morning in order to help her focus and become less stressed over the possibility of poor school performance.

After two weeks, the provider increased her dosage to 60 mg every morning and also started her on dextroamphetamine sulfate tablets (10 mg) that she took daily in the afternoon in order to improve her concentration and ability to study. Shanta claimed that she might have taken up to three dextroamphetamine sulfate tablets over the past three days because she was worried about falling asleep and being unable to adequately prepare for an examination.

Prior to the ADHD diagnosis, the patient had no known psychiatric or substance abuse history. The urine toxicology screen taken upon admission to the emergency department was positive only for amphetamines. There was no family history of psychotic or mood disorders, and she didn’t exhibit any depressive, manic, or hypomanic symptoms.

The stimulant medications were discontinued by the hospital upon admission to the emergency department and the patient was treated with an atypical antipsychotic. She tolerated the medications well, started psychotherapy sessions, and was released five days later. On the day of discharge, there were no delusions or hallucinations reported. She was referred to the local mental health center for aftercare follow-up with a psychiatrist. [2]

Another powerful case study example is that of Elyn R. Saks, the associate dean and Orrin B. Evans professor of law, psychology, and psychiatry and the behavioral sciences at the University of Southern California Gould Law School.

Saks began experiencing symptoms of mental illness at eight years old, but she had her first full-blown episode when studying as a Marshall scholar at Oxford University. Another breakdown happened while Saks was a student at Yale Law School, after which she “ended up forcibly restrained and forced to take anti-psychotic medication.” Her scholarly efforts thus include taking a careful look at the destructive impact force and coercion can have on the lives of people with psychiatric illnesses, whether during treatment or perhaps in interactions with police; the Saks Institute, for example, co-hosted a conference examining the urgent problem of how to address excessive use of force in encounters between law enforcement and individuals with mental health challenges.

Saks lives with schizophrenia and has written and spoken about her experiences. She says, “There’s a tremendous need to implode the myths of mental illness, to put a face on it, to show people that a diagnosis does not have to lead to a painful and oblique life.”

In recent years, researchers have begun talking about mental health care in the same way addiction specialists speak of recovery—the lifelong journey of self-treatment and discipline that guides substance abuse programs. The idea remains controversial: managing a severe mental illness is more complicated than simply avoiding certain behaviors. Approaches include “medication (usually), therapy (often), a measure of good luck (always)—and, most of all, the inner strength to manage one’s demons, if not banish them. That strength can come from any number of places…love, forgiveness, faith in God, a lifelong friendship.” Saks says, “We who struggle with these disorders can lead full, happy, productive lives, if we have the right resources.”

You can view the transcript for “A tale of mental illness | Elyn Saks” here (opens in new window) .

• Bai, Y., Yang, X., Zeng, Z., & Yang, H. (2018). A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. BMC psychiatry , 18(1), 67. https://doi.org/10.1186/s12888-018-1655-5 ↵
• Henning A, Kurtom M, Espiridion E D (February 23, 2019) A Case Study of Acute Stimulant-induced Psychosis. Cureus 11(2): e4126. doi:10.7759/cureus.4126 ↵
• Modification, adaptation, and original content. Authored by : Wallis Back for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A tale of mental illness . Authored by : Elyn Saks. Provided by : TED. Located at : https://www.youtube.com/watch?v=f6CILJA110Y . License : Other . License Terms : Standard YouTube License
• A Case Study of Acute Stimulant-induced Psychosis. Authored by : Ashley Henning, Muhannad Kurtom, Eduardo D. Espiridion. Provided by : Cureus. Located at : https://www.cureus.com/articles/17024-a-case-study-of-acute-stimulant-induced-psychosis#article-disclosures-acknowledgements . License : CC BY: Attribution
• Elyn Saks. Provided by : Wikipedia. Located at : https://en.wikipedia.org/wiki/Elyn_Saks . License : CC BY-SA: Attribution-ShareAlike
• A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. Authored by : Yuanhan Bai, Xi Yang, Zhiqiang Zeng, and Haichen Yangcorresponding. Located at : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851085/ . License : CC BY: Attribution

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Case Report: Schizophrenia Discovered during the Patient Interview in a Man with Shoulder Pain Referred for Physical Therapy

Purpose: The purpose of this case report is to demonstrate the importance of a thorough patient interview. The case involves a man referred for physical therapy for a musculoskeletal dysfunction; during the patient interview, a psychiatric disorder was recognized that was later identified as schizophrenia. A secondary purpose is to educate physical therapists on the recognizable signs and symptoms of schizophrenia.

Client description: A 19-year-old male patient with chronic shoulder, elbow, and wrist pain was referred for physical therapy. During the interview, the patient reported that he was receiving signals from an electronic device implanted in his body.

Measures and outcome: The physical therapist's initial assessment identified a disorder requiring medical referral. Further management of the patient's musculoskeletal dysfunction was not appropriate at this time.

Intervention: The patient was referred for further medical investigation, as he was demonstrating signs suggestive of a psychiatric disorder. The patient was diagnosed with schizophrenia by a psychiatrist and was prescribed Risperdal.

Implications: This case study reinforces the importance of a thorough patient interview by physical therapists to rule out non-musculoskeletal disorders. Patients seeking neuromusculoskeletal assessment and treatment may have undiagnosed primary or secondary psychiatric disorders that require recognition by physical therapists and possible medical referral.

RÉSUMÉ

Objectif : L'objectif de cette étude de cas consiste à démontrer l'importance de réaliser des entrevues en profondeur avec les patients. Le cas étudié concerne un homme dirigé vers la physiothérapie en raison d'une dysfonction musculosquelettique. Au cours de l'entrevue avec ce patient, un problème psychiatrique a été décelé; par la suite, de la schizophrénie a été diagnostiquée. Le deuxième objectif de cette étude de cas est d'éduquer et de sensibiliser les physiothérapeutes aux signes et aux symptômes aisément reconnaissables de la schizophrénie.

Description du client : Le patient est un jeune homme de 19 ans qui souffre de douleurs chroniques à l'épaule, au coude et au poignet et qui avait été dirigé en physiothérapie. Au cours de l'entrevue, le patient a déclaré qu'il recevait des signaux provenant d'un appareil électronique implanté dans son corps.

Mesures et résultats : L'évaluation préliminaire du physiothérapeute a permis d'identifier un problème qui nécessitait que le patient soit redirigé vers un médecin. Une gestion plus poussée de la dysfonction musculosquelettique de ce patient a été jugée inappropriée à cette étape.

Intervention : Le patient a été dirigé vers une investigation médicale plus approfondie, puisqu'il manifestait des signes de possibles problèmes psychiatriques. Le patient a par la suite été diagnostiqué comme schizophrène et on lui a prescrit du Risperdal.

Implication : Cette étude de cas vient réaffirmer l'importance, pour le physiothérapeute, de procéder à des entrevues approfondies avec les patients pour s'assurer qu'il n'y a pas d'autres problèmes que les seules dysfonctions musculosquelettiques. Les patients qui souhaitent obtenir une évaluation et un traitement musculosquelettique peuvent souffrir aussi d'un problème psychiatrique primaire ou secondaire non diagnostiqué qui exige d'être reconnu par le physiothérapeute et qui nécessitera vraisemblablement une attention médicale ultérieure.

INTRODUCTION

A recent US study demonstrated that less than one-third of diagnoses provided to physical therapists by primary-care physicians are specific. 1 The same study illustrated that physical therapists must assume a greater diagnostic role and must routinely provide medical screening and differential diagnosis of pathology during the examination. 1 Similarly, studies conducted in Australia and Canada have concluded that the majority of referrals for physical therapy are not provided with a specific diagnosis. 2 , 3 Medical screening is important, since physical therapists are increasingly functioning as the primary contact for patients with neuromusculoskeletal dysfunctions, 4 , 5 which means a greater likelihood of encountering patients with non-musculoskeletal disorders, including psychiatric disorders.

As demonstrated by the World Health Organization's International Classification of Functioning, Disability and Health, it is imperative to take an individual's psychological state into account, since disorders in this area can lead to disability. 6 Many psychiatric conditions are commonly encountered in physical therapy practice; for example, depression, anxiety, and fear-avoidance have all been associated with low back, neck, and widespread musculoskeletal pain. 7 – 9 These psychiatric disorders have been identified both as risk factors for musculoskeletal dysfunction and as an important secondary psychosocial aspect of disablement. 7 – 10 It is therefore important for physical therapists to consider the primary and secondary roles of psychopathology in disability.

Although various models of primary-care physical therapy have demonstrated physical therapists' expertise in the realm of neuromusculoskeletal dysfunctions, there is a need for increased competencies in academic, clinical, and affective domains. 5 Few et al. propose a hypothesis-oriented algorithm for symptom-based diagnosis through which physical therapists can arrive at a diagnostic impression. 11 This algorithm takes into account the various causes of pathology, including psychogenic disorders. 11 Although additional research is necessary to validate Few et al.'s algorithm, it provides one model that considers underlying pathologies in determining the appropriateness of physical therapy intervention. 11 The present case report further illustrates the importance of considering the patient's affective and psychological state in order to more effectively screen for and identify psychiatric disorders that require medical referral.

The purpose of this case report is to demonstrate the importance of a thorough patient interview. We present the case of a man, referred for physical therapy for a musculoskeletal dysfunction, who was determined during the patient interview to have an undiagnosed psychiatric disorder, later identified as schizophrenia. In addition, this report is intended to educate physical therapists about the recognizable signs and symptoms of schizophrenia.

CASE DESCRIPTION

The patient was a 19-year-old male university student. His recreational activities included skateboarding, snowboarding, break dancing, and weight training. The patient first sought medical attention from a sport medicine physician in January 2006, when he reported right lateral wrist pain since falling and hitting the ulnar aspect of his wrist while skateboarding in October 2005. Plain film radiographs taken after the injury were negative, and the patient did not receive any treatment. The physician found no wrist swelling, minimal tenderness over the ulnar aspect of the right wrist, full functional strength, and minimally restricted range of motion (ROM). The patient was given ROM exercises and was diagnosed with a right wrist contusion.

Over the next 22 months, the patient returned to the same sport medicine clinic 10 times, reporting pain in his wrist, shoulder, elbow, knee, ankle, and neck. He stated that the elbow, wrist, and shoulder injuries were due to falls while skateboarding and snowboarding or to overuse during weight training; some injuries had no apparent cause. Over the course of his medical care, the patient followed up with three different physicians at the same clinic. He was diagnosed by these physicians, in order of occurrence, with (1) right wrist contusion and sprain; (2) right wrist impingement and left wrist strain; (3) right shoulder supraspinatus tendinopathy; (4) right peroneal overuse injury and strain; (5) disuse adhesions of the right peroneals and right hip adhesions; (6) right ankle neuropathic pain secondary to nerve injury and sprain and right-knee patellofemoral pain syndrome (PFPS); (7) neuropathic pain of the right peroneal nerve; (8) trauma-induced left-knee PFPS; (9) ongoing post-traumatic left-knee PFPS; and (10) right levator scapula strain, chronic right infraspinatus strain, right elbow ulnar ridge contusion, and right wrist chronic distal ulnar impingement secondary to malaligned triangular fibrocartilage complex (TFCC).

After his tenth visit to a physician, the patient was referred for physical therapy for chronic right levator scapula strain and right supraspinatus strain. During the interview, the patient stated that he had right shoulder pain because of a snowboarding injury sustained 1 year earlier and because of a fall onto the lateral right shoulder 2 years ago. Aggravating activities to the shoulder included pull-ups, rowing, and free weights. No position or movement alleviated his pain, and the pain did not fluctuate over the course of the day. His sleep was disturbed only when lying on the right shoulder. The patient was in generally good health, but he said that his right wrist and left knee occasionally felt cold for no apparent reason. He denied experiencing any loss of sensation, decreased blood flow, or numbness or tingling in the knee and wrist. The patient said he believed that his knee and wrist became cold as a result of electromagnetic impulses sent to the joint via an electrical implant in his body and that this device was the cause of his ongoing shoulder pain.

According to the patient, this device had been implanted into his body 2 years earlier by a government organization (the Central Intelligence Agency, the US government, or the US Army) to control his actions. Electromagnetic impulses generated by the implant had caused his falls and injuries; they also caused his joints to become cold or painful when he was doing something “they” did not want him to do, such as break dancing, snowboarding, skateboarding, or exercising. The patient also believed that many other people unknowingly had implants; he claimed that friends, neighbours, professors, and strangers were “working with them” and that they “emotionally abuse[d]” him by giving signs such as kicking a leg back to let him know he was being watched. Furthermore, he indicated that he often received commands telling him to harm his friends or family and that these orders came either from the electrical implant or from the people he claimed were emotionally abusing him. He therefore distanced himself from some friends because he did not want to follow through with these commands. I asked the patient if he felt he would harm himself or others because of his psychotic-like symptoms. He denied any desire to inflict harm on himself or others. Had he posed a threat to himself or others, he would have been “formed” (i.e., committed to a psychiatric facility by the appropriate medical professional).

The patient's past medical and family history were unremarkable. He did not use any prescription or over-the-counter medications, but he felt his thoughts about electrical implants were decreased by the use of marijuana, which he used socially. He was a non-smoker and a social consumer of alcohol. He had a normal gait and appeared comfortable in an unsupported seated position. He denied any weight changes, bowel or bladder problems, night pain, or difficulty breathing.

PHYSICAL EXAMINATION

The patient reported a maximum verbal numeric pain rating scale (NPRS) score of 8/10 and a minimum score of 0/10, with pain usually present in the shoulder. In a double-blind, placebo-controlled, multi-centre chronic pain study, when the baseline NPRS raw score fluctuated by 0 points, the sensitivity and specificity were 95.32% and 31.80% respectively; 12 , 13 when there was a 4-point raw score change, the sensitivity and specificity were 35.92% and 96.92% respectively. 12 The patient stated that when he experienced shoulder pain, it was located on the anterior, posterior, and lateral aspects of his shoulder and radiated down to his elbow and wrist. He reported 0/10 shoulder pain while seated.

Standing posture was assessed in the frontal and sagittal planes. 14 The patient had a mild forward head posture and internally rotated glenohumeral joints in the sagittal plane. The frontal-plane analysis revealed a slight elevation of the right shoulder and level iliac crests. Such visual assessment of cervical and lumbar lordosis has an intrarater reliability of k =0.50 but an interrater reliability of k =0.16. 15

In the frontal plane, the right scapula was abducted four finger-widths from the mid-thoracic spine, and the left scapula was abducted three finger-widths. The scapulas were superiorly rotated bilaterally. Surface palpation of the acromial angle, inferior angle, and spine of the scapula differed less than 0.98 cm, 0.46 cm, and 0.67 cm, respectively, from the actual bony location, with a 95% confidence interval. 16 There was visible hypertrophy of the pectoralis major muscle bilaterally. Active and passive ROM were tested for the shoulders as recommended by Magee. 14 The patient had full bilateral active ROM, with minimal pain at end-range flexion and abduction that was not increased with overpressure in accordance with Magee. 14 He had full passive ROM with no pain reported.

Manual muscle testing based on Hislop and Montgomery revealed 4/5 strength of external rotation at 0° and 45° of abduction, with pain reported along the anterolateral shoulder. 17 Testing also showed 3/5 strength and no pain with resisted abduction with the arm at the side at approximately 30° of abduction. 18 Manual muscle testing is a useful clinical assessment tool, although a recent literature review suggested that further testing is required for scientific validation. 18 Palpation of the shoulder, as described by Hoppenfeld, revealed slight tenderness over the greater tubercle, as well as along the length of the levator scapula muscle. 19

Special tests were negative for the sulcus sign, Speed's test, the drop arm test, and the empty can test, as described by Magee. 14 Research shows that Speed's test has a sensitivity and specificity of 32% and 61% for biceps and labral pathology respectively; 20 the drop arm test has a sensitivity of 27% and a specificity of 88% as a specific test for rotator cuff tears, and the empty can test has a sensitivity of 44% and a specificity of 90% in diagnosing complete or partial rotator cuff tears. 20 , 21 The Neer and Hawkins-Kennedy impingement tests were both negative. 14 According to a meta-analysis by Hegedus et al., the Neer test is 79% sensitive and 53% specific, while the Hawkins-Kennedy test is 79% sensitive and 59% specific, for impingement. 21

I (NS) diagnosed the patient with mild supraspinatus tendinosis, with no evidence of tearing of the rotator cuff muscles, based on the following findings drawn from the patient interview: shoulder pain aggravated by pull-ups, rowing, and free weights; increased pain when lying on the affected shoulder. Additional significant findings from the physical examination included full shoulder active ROM with minimal pain at end-range flexion and abduction; pain along the anterior lateral shoulder with resisted testing of external rotation at 0° and 45° of abduction; negative drop arm and empty can tests; and tenderness over the greater tubercle of the humerus. The musculoskeletal dysfunction did not explain the level of pain reported by the patient (maximum NPRS 8/10), nor was the physical examination able to reproduce the exact location of the reported shoulder pain or the elbow, wrist, and knee pain described by the patient.

I was concerned about a serious pathology or a psychological disorder, given that this 19-year-old had made 10 medical appointments over 22 months for 6 different regions of the body; in my experience of examining and treating patients between the ages of 18 and 25, the frequency of the appointments and the variation in afflicted body parts are not typical of a young patient. The patient's description of his shoulder pain, in terms of location and severity, was not reproducible by physical examination. Throughout our interview, the patient did not maintain good eye contact, spoke in a monotone voice, and had an overall flat affect. Even when he described his beliefs about implants and government control, his voice and demeanour remained expressionless. The patient described persecutory delusions, command hallucinations, and social isolation from friends and family, all of which are signs of psychosis according to the Diagnostic and Statistical Manual of Mental Health . 22

Based on the findings from the patient interview and the physical examination, the patient did have symptoms consistent with a known musculoskeletal dysfunction; however, the undiagnosed and uncontrolled psychiatric symptoms made it more appropriate to refer him back to the physician for evaluation and treatment of his psychosis than to provide physical therapy intervention for his shoulder dysfunction. Furthermore, because research shows that the rate of suicide among patients with schizophrenia can range from 2% or 4% to as high as 15% 23 , 24 and that the rate of suicide is highest among patients close to the date of diagnosis, early recognition is crucial. 23

INTERVENTION

Based on the findings from the patient interview and the signs and symptoms of psychiatric disorders, I explained to the patient that there was a need for further medical investigation. Although the patient did not agree with this initial assessment, he did consent to a follow-up with the referring physician.

I spoke to the referring physician in person and explained to him my findings from the patient interview, specifically the patient's belief that he had electrical implants in his body. I also pointed out the patient's affect and the limited physical findings during the physical examination. I provided the physician with some direct quotes from the patient to demonstrate the level of psychosis he was presenting with. I stated my conclusion that the patient was suffering from some form of psychosis that precluded physical therapy treatment for his shoulder at that time. The referring physician was quite concerned about the patient and called him during our meeting to arrange a follow-up medical appointment.

The physician examined the patient, made similar observations, concurred with my assessment, and concluded that the patient was experiencing some form of psychosis. The plan of care involved referral to a psychiatrist, follow-up with the physician, and explaining to the patient that physical therapy would not be appropriate at this time because of the presence of a serious psychiatric disorder. The patient did not believe that he had a psychiatric disorder, but he was willing to follow up with a psychiatrist. The physician noted that the patient was not a threat to himself or others and that he did not report having homicidal or suicidal thoughts.

The patient followed up with the psychiatrist 11 days after his appointment with the physician. He was diagnosed with schizophrenia and started on a daily dose of risperidone (Risperdal). The patient was also instructed to follow up with the psychiatrist every second week to ensure compliance with the medication and to discuss progress. Further details of the psychiatric assessment and treatment were not available for this case report. Outcomes are also unavailable for this case report, since follow-up by the physical therapist was not possible.

Case Summary

This case report describes a 19-year-old man referred to physical therapy with shoulder, wrist, and knee pain who was later diagnosed with a psychiatric disorder. After completing a thorough patient interview and physical examination, I concluded that the patient was suffering from an undiagnosed psychiatric disorder that required medical referral. The interview revealed that the patient had delusions about electrical devices' being implanted in his body and was experiencing various forms of hallucination. The patient was promptly referred for medical consult and was diagnosed with schizophrenia by a psychiatrist.

Patient Symptoms and Schizophrenia

Schizophrenia is a psychiatric disorder affecting between 0.5% and 1.5% of adults worldwide, with a slightly greater prevalence in men. 22 The age of onset may be from 5 to 60 years; however, more than 50% of first episodes occur between the ages of 15 and 24. 22 , 25 , 26 An earlier onset is more common among men, while later onset is more common among women. 25 Schizophrenia shows a higher incidence in individuals born in urban areas than in those born in rural areas. 22 , 25 Because the patient in the present case fell into several of these categories (male, born in an urban area, experienced onset of symptoms around age 17) and presented with clear symptoms of a psychiatric disorder (delusions, hallucinations), schizophrenia seemed the most likely diagnosis.

The signs and symptoms of schizophrenia are classified as either positive or negative. 22 Positive symptoms are an excess of normal function and include delusions, hallucinations, and disorganized speech; 22 , 27 negative symptoms are a deficiency of normal function and include limited goal-directed behaviour (avolition), limited fluency and productivity of speech and thought, and a flat affect. 22 , 27 The diagnosis of schizophrenia requires the presence of at least two of these positive or negative symptoms lasting at least 6 months. 22 , 27 In this case, the patient presented with delusions (e.g., electrical implants trying to control his and others' actions), including persecutory delusions (e.g., “they are emotionally abusing me”), hallucinations (e.g., hearing voices, seeing signs), and a flat affect. Since the patient was enrolled in university at the time of diagnosis, his cognitive function is assumed to be well preserved. The patient reported no change in symptoms for 2 years.

Schizophrenia is subdivided into five types: paranoid, disorganized, catatonic, undifferentiated, and residual (see Table ​ Table1 1 ). 22 , 28 Based on these observations and on the literature, the patient's symptoms were suggestive of paranoid schizophrenia, 22 which is the most prevalent form of schizophrenia in most parts of the world. 22

Schizophrenia Subtypes 6

The aetiology of schizophrenia remains unknown. 29 , 30 There is a strong genetic predisposition. 29 , 30 Patients who experience the onset of schizophrenia before age 22 are 10 times more likely to have a history of a complicated caesarean birth than patients with a later onset of schizophrenia, which suggests a possible neurodevelopmental factor in early-onset schizophrenia. 31 Mild childhood head injuries may play a role in the expression of schizophrenia in families with a strong genetic predisposition to this disorder. 32 Psychological stress has also been implicated in the onset of schizophrenia, since it often precipitates the first psychotic episode or increases the likelihood of a relapse. 33 , 34 In this case, the patient described a family “break-up” which may have precipitated the onset of psychosis. Details about his childhood head injuries and the circumstances of his birth were not obtained. After being diagnosed with schizophrenia, the patient revealed to the referring physician that his father had experienced something similar when he was younger, which may point to a genetic predisposition.

There are no conclusive diagnostic tests for schizophrenia. 22 However, imaging studies have suggested neurophysiologic changes as an associated finding. Volumetric magnetic resonance imaging (MRI) studies of patients with schizophrenia have demonstrated an overall reduction in grey matter; an increase in white matter; decreased size of the amygdala, hippocampus, and parahippocampus; an overall reduction in brain volume; and larger lateral ventricles relative to a control group. 35 – 37

Psychiatric Disorders as They Relate to Musculoskeletal Dysfunction

As primary-care practitioners, physical therapists may encounter patients with possible psychiatric disorders such as schizophrenia. However, the physical therapy literature on psychiatric disorders as they relate to musculoskeletal disorders focuses mainly on low back pain (LBP). 7 , 8 In an examination of a large number of physical and psychological factors, one prospective case-control study points to the importance of psychological variables as a risk factor for chronic LBP and widespread musculoskeletal pain. 8 Previous research has also concurred with this study in implicating psychological variables as risk factors for LBP and neck pain. 9 , 10 These articles provide a link between psychological disorders and patients seeking physical therapy for musculoskeletal dysfunctions.

In this case report, the physical examination was suggestive of a mild supraspinatus tendinosis, but this did not explain the severity of pain reported by the patient or the referral of pain to the elbow, wrist, and knee. One of the limitations of the physical examination was that there was not sufficient time to perform physical examination of the elbow, wrist, and knee. The patient's undiagnosed and uncontrolled psychiatric symptoms took priority over the musculoskeletal dysfunction and required immediate medical referral without physical therapy intervention. Because of the inconsistencies between interview and physical examination, as well as the patient's perception that an electrical implant was causing his musculoskeletal pain, there is a possibility that at least some of his musculoskeletal symptoms may have been manifestations of his psychiatric disorder.

Effective Patient Interviews

The medical literature indicates that 50% of all mental illness is recognized during the interview process as part of medical assessment by the primary-care physician. 38 As physical therapists embrace their role as providers of primary care, 4 , 5 they must rely on their skills in patient interviewing and physical examination to rule out medical pathology. Improved assessment skills by the physical therapist may help to identify primary or secondary medical pathologies that have not previously been diagnosed. Within the peer-reviewed literature, a number of case studies demonstrate identification of non-musculoskeletal or visceral pathology that can manifest as musculoskeletal disorders; 39 – 41 these case studies are examples of how physical therapists can perform an initial assessment, identify a medical pathology that precludes treatment, and make an appropriate referral. During a patient interview, physical therapists must be well aware of the psychological and psychosocial aspects of the examination to identify relevant aspects of the patient's demeanour (e.g., appropriate self-care) and emotional state (e.g., inappropriate affect). The patient interview should consist of non-leading, open-ended questions about how pain in multiple areas is related and how it is caused. Furthermore, physical therapists should avoid rationalizing the patient's symptoms during the interview process. At a minimum, patients should be permitted to speak about and describe their symptoms in a way that is meaningful to them.

Schizophrenia and Primary Care

Schizophrenia is most often initially recognized by the primary-care physician. 42 Psychiatrists, psychologists, and even the lay community have also been noted in the literature as making the initial identification. 43 – 45 Although conspicuously absent from the literature on the initial identification of schizophrenia, physical therapists are in a position to be important first-contact care providers who can make the initial identification of schizophrenia, and other psychiatric disorders, through effective patient interviews. Although labelling patients as having a psychiatric disorder is outside physical therapists' scope of practice, the diagnostic process is not exclusive to any one profession. In this case, the process of diagnosis, which involves assessing the patient, grouping findings, interpreting the data, and identifying the patient's problems, led me to conclude that the primary dysfunction was psychiatric in nature. 46 This process, which Few et al. call “diagnostic reasoning,” is well within physical therapists' scope of practice and is something we constantly engage in during our daily clinical practice. 11 Diagnostic reasoning involves taking into account all of the possible pathological structures and determining the most likely cause of the patient's symptoms. In practice, expert clinicians do not follow standardized protocols; 46 rather, they pay attention to cues provided by the patient, recognize patterns, and test hypotheses to arrive at a probable cause for the patient's symptoms. 11

IMPLICATIONS AND FUTURE DIRECTIONs

The medical literature has identified gaps in the knowledge of primary-care physicians, specifically a lack of awareness of the symptoms and epidemiology of schizophrenia. 28 To facilitate early recognition, referral, and diagnosis of schizophrenia, the medical literature has suggested increased collaboration among family physicians and mental-health professionals, as well as ongoing mental-health training for family physicians. 47 , 48 Physical therapists should also heed these suggestions. A study in the physical therapy literature recommends mental-health training for recognizing the symptoms of depression in a population with LBP; 7 the same study, conducted in Australia, concluded that physical therapists' ability to recognize depressive symptoms in an outpatient setting was poor. 7

An initial step to address these gaps could be a position paper that draws on the medical literature to inform physical therapists about the presence, prevalence, signs, and symptoms of common psychiatric disorders. As well, future research needs to focus on the incidence of musculoskeletal signs and symptoms in patients with common psychiatric disorders.

KEY MESSAGES

What is already known on this topic.

To the authors' knowledge, there are no known studies in the literature describing a case of a patient referred to physical therapy for musculoskeletal dysfunction who was later diagnosed with schizophrenia.

What This Study Adds

This case report contributes to the existing literature on physical therapists functioning as competent providers of primary care who have the knowledge and skills needed to rule out non-musculoskeletal pathology. It also educates physical therapists about the signs and symptoms of schizophrenia.

Shah N, Nakamura Y. Case report: schizophrenia discovered during the patient interview in a man with shoulder pain referred for physical therapy. Physiother Can. 2010;62:308–315

• Research article
• Open access
• Published: 05 January 2021

Family achievements in struggling with schizophrenia: life experiences in a qualitative content analysis study in Iran

• Fatemeh Darban 1 ,
• Roghayeh Mehdipour- Rabori 2 ,
• Jamileh Farokhzadian 2 ,
• Esmat Nouhi 2 &
• Sakineh Sabzevari   ORCID: orcid.org/0000-0002-9021-7101 2  

BMC Psychiatry volume  21 , Article number:  7 ( 2021 ) Cite this article

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The challenges of living with and taking care of a patient with schizophrenia can lead to positive changes depending on the experiences and reactions of family caregivers. Such changes may directly affect the family performance and the patient’s recovery stage. Present study aimed to explain the positive experiences reported by family caregivers of patients with schizophrenia.

The present study is a qualitative study of content analysis. Data were collected using semi-structured and in-depth interviews with 15 family caregivers of patients with schizophrenia referring to one of the psychiatric hospitals in Zahedan, Southeast part of Iran. Purposive sampling method was applied and data analysis was conducted using conventional content analysis proposed by Graneheim and Lundman.

Data analysis created a theme entitled “family achievements in struggling with schizophrenia”. This theme included four categories including Developing positive personality traits in family members, Strengthening family ties, developing insight into the life, and social mobility.

Conclusions

The results provided insights that the experience of taking care of patients with schizophrenia led to positive consequences for family caregivers. Thus, it is recommended that psychiatrists or consultants help families rely on positive experiences and share these experiences with families with a newly-suffered patient.

Peer Review reports

Schizophrenia is one of the most chronic and debilitating psychiatric disorders [ 1 ] with a prevalence of 1.4–4.6 per 1000 persons [ 2 ]. Early-onset of the disease, long term persistence of the symptoms, and recurrence of the disease cause economic, social, and individual problems. As a result, high therapeutic and non-therapeutic costs are imposed on the family and community, such as losing a job due to illness or taking care of the loved ones [ 3 , 4 ]. This disease is ranked eleventh among 301 diseases and injuries [ 5 , 6 , 7 ]. Families with schizophrenic patients experience grief and have to deal with social stigma and isolation leading to feelings of shame or guilt and affect their physical and mental health [ 8 ]. Although most of the consequences of caring for a patient with schizophrenia are negative, some family caregivers have identified more positive and beneficial aspects of this role in recent years [ 9 , 10 ]. Although little study has been performed in this area, the evidence show that caring for others can result in positive changes in one’s life. Other diagnostic changes can have a positive effect on family members, such as improving the family dynamics, having more social support, and having an outdoor job (for both the patient and the caregiver) [ 11 , 12 ]. Positive family characteristics such as warmth and cohesion may have a protective effect that helps to improve the symptoms of schizophrenia [ 13 ]. In a study conducted by Chen and Greenberg (2004), approximately 70% of the caregivers reported that they became more sensitive towards people with disabilities and 50% felt more empowered internally [ 14 ]. Pickett et al. reported that positive assessments of parents’ relationship with the sick child were significantly associated with reduced caregiver burden [ 15 ].

Evaluation of the disease consequences depends on the experiences and reactions of the families and patients, which may directly affect the family performance and the patient’s recovery stage [ 16 , 17 ]. Furthermore, studies show that family structures may vary within different cultural contexts. For example, Weisman et al. (2016) mentioned that the more cohesive the African-American families of patients with schizophrenia are, the less anxious they will be. in [ 18 ]. A study indicated that Latin American families managed to accept the patient’s current disabilities and they hope for the future [ 3 ]. In Iran, there is a traditional family structure and people with schizophrenia are mostly cared for by their families. In Iranian culture, family ties are important factors in everyday life. The whole family handle their problems and reduce the burden of care [ 19 ]. Despite the positive aspects of family care, no study has ever assessed the positive aspects of caring for patients with mental disorders in Iran. The treatment and care team should understand the importance of this issue in providing appropriate care to patients. In other words, these positive family changes can result in medical treatment decisions that enhance disease outcomes. As a result, family caregivers’ experiences should be evaluated comprehensively and deeply. Family caregivers’ experiences can provide the researchers with information about their unique situation and enhance their performance in caring patient [ 20 ]. Such experiences can be determined through effective communication and in-depth interviews. Considering the paucity of information about experiences of family caregivers with schizophrenia patients, we decided to explore this issue considering the cultural, religious, and social aspects of the Iranian families.

Study design and setting

This qualitative study was conducted using a conventional content analysis method. This systematic method is applied to describe a phenomenon deeply and release information to determine its patterns and communication processes [ 21 ].

This study was performed in Zahedan metropolis, the capital of Sistan and Baluchestan province, southeast of Iran. The residents of this city are of Baloch and Sistani ethnicity. The Baloch speak the Balochi dialect and are Sunni Muslims. The Sistani speak a dialect of Persian and are Shia Muslims [ 22 ]. Despite the difference in language and religious beliefs, the residents of this region always tried to meet their shared needs by interacting with each other while maintaining cultural commonalities. They understand each other’s language and live together; get married and have joint representatives in the Islamic Consultative Assembly. Hospitals and the health system employ people from both classes to provide appropriate cultural services. These interactions result in developing a common culture called the culture of Sistan and Baluchestan, which is part of the culture of the southeast of Iran.

The sampling was conducted in a large Educational Psychiatric Hospital in Zahedan, which is the only psychiatric hospital in this city with 100 active beds. The present study was conducted from August 2019 to February 2020.

Participants

In the present study, researchers used purposive sampling techniques to select participants with different socio-demographic backgrounds to achieve more in-depth information on thei r lived experiences. In the hospital, the researcher referred to the inpatient medical records in different wards of the hospital to select several eligible participants. The first researcher collected the patients’ telephone number and address registered in the records and made the necessary arrangements for the interviews. Participants included family caregivers of patients with schizophrenia, who met the following criteria: having a family member with schizophrenia (diagnosed by a psychiatrist), being 18 years old and higher [ 23 ], and having favorable physical and mental conditions, living with and taking care of the patient directly, passing at least 1 year from the diagnosis of schizophrenia [ 24 ], as well as having the ability to understand and speak Persian or Persian dialects - Baluchi and Sistani . Sampling continued until information was saturated and no new conceptual information was obtained [ 25 ]. The researchers prioritized the representation of variations in experience, gender, socioeconomic status, level of education, and ethnicity in the participants.

Data collection

Data were collected using in-depth, face-to-face, and semi-structured interviews. Initially, the first researcher contacted each participant and scheduled an agreed-upon date and time to conduct the interview. The participant met the inclusion criteria and had consented to participate in the study. All eligible participants were willing to cooperate in the study. The interviews were followed by a topic guide; A list of some helpful questions was prepared by the research team according to the study purpose The Guide of the interview is available in Additional file  1 . During the interviews, some questions were also added to the list according to the obtained data. The interview questions were mainly about the family caregivers’ positive experiences in living and taking care of the patient with schizophrenia. The subsequent follow-up questions were gradually raised based on the information provided by the participants for more clarifications. To achieve deeper information, in-depth questions, such as “What do you mean?” Or “Please explain more” were used. A large amount of the data was recollected after the seventh interview and data saturation in the thirteenth interview, but the interviews were continued up to 15 for reassurance. As the participants preferred, the interviews were conducted in the psychologist’s room in the hospital, which is a quiet room. The interviews were performed in Persian ( N =7) and Balochi dialect ( N =8). All Balochi interviews were conducted and translated into Persian before data analysis by F. D (the first author). F. D is a native Balochi and Persian speaker and familiar with a combination of Balochi and Sistani culture. The interviews lasted 45–90 min.

All interviews were recorded with the consent of the participants. The recorded files were transcribed verbatim; even the participants’ nonverbal gestures and body movements were mentioned in the transcriptions. The interview process was evaluated by the second and third researchers, who are experts in qualitative study.

Data collection and analysis were performed simultaneously. The MAXQDA.18 used to facilitate organization and comparison of the data.

The transcription of each interview was reviewed several times. The qualitative data content analysis process was performed according to the method proposed by Graneheim and Lundman, including writing the entire interview, reading the entire text of interviews several times to achieve a general understanding of its content and immersion in the data, determining semantic units and summarizing them, extracting the primary codes, classifying the similar primary codes under the same subcategories, classifying similar codes under more comprehensive categories, extracting latent and manifest concepts from the data, and formulating the final themes [ 21 ]. To this end, after preparing the transcriptions, each text was reviewed several times. Later, the semantic units were identified based on the research questions and appropriate codes were written for each semantic unit. As shown in Table  1 , the preliminary codes were categorized and labeled based on their conceptual similarity (subcategories). The subcategories were compared and placed under the main categories, which were more abstract (categories). The main categories were categorized under a more abstract concept (theme).

All extracted codes and categories were reviewed and approved by the second and fifth authors of this study. The initial extracted codes were reduced by continuous data analysis and comparison; finally, the categories and subcategories were abstracted.

Lincoln and Guba criteria (credibility, dependability, confirmability, and transferability) were used to ensure The data trustworthiness [ 26 ]. To ensure the results credibility, participants were asked to confirm the extracted codes from the interview and resolve the contents on demand (member check). Data-source triangulation from interviews with family caregivers with variety in relationship with patient, ethnicity and religion established credibility. Regarding confirmability of the findings, all texts of the interviews, codes, and categories were reviewed and confirmed by the second, third, and fifth authors of this study (peer check) as well as a faculty member outside the research area (faculty check). To ensure the dependability of the results, all stages of the study were recorded. Participants were selected by maximum variation sampling in terms of ethnicity, level of education, religion, economic status, relation to the patient, and social class, which enhanced the transferability of the study.

A total of 15 interviews were conducted with the family caregivers of schizophrenic patients about the positive consequences of schizophrenia for the family. Participant characteristics are shown in Table  2 . The family caregivers included 11 females and 4 males with monthly income ranging from 10 to 50 million rials. 8 of them were Baloch and 7 Sistani ethnicity (Table 2 ). Their patients included 6 females and 9 males aged 26–56 years, and a 5–22 years of disease duration. Two patients had a university degree and the others had a high school or lower education. All but one patient were Unemployed.

As shown in Table 3 , Data analysis resulted in a theme entitled “family achievements in struggling with schizophrenia”, which included four categories and 17 subcategories: Developing positive personality traits in family members (being able to express emotions easily, being stronger in the face of life problems, making greater intellectual developments than peers, being patient, having enhanced communication skills, achieving independence faster, and having increased ability to understand others); Strengthening family ties (increasing dependence and affection among family members, developing family members’ empathetic participation in caring patient, and increasing support among family members); Developing insight into the life (understanding the importance of mental health, changing mindset from comfort to peace in life, feeling the presence of superior power in life); and Social mobility (a flip to change lifestyles, acquiring and enhancing capabilities, Economic dynamism, Dynamism in social services).

Developing positive personality traits in family members

Based on the findings, living with and caring for a patient with schizophrenia caused significant changes in people’s daily lives. Adaptation to these changes resulted in the development of positive personality traits in people who were living with these patients. According to the participants’ experiences, seven subcategories were obtained concerning the development and growth of positive personality traits in the patient’s family members.

Being able to express emotions easily

Based on the participants’ experiences, the challenges of living with a patient with schizophrenia caused them to show their emotions (e.g., happiness or sadness) more openly and to react emotionally to small events. Their feeling of compassion to the patient had led them to show this feeling to others.

“ My heart goes out to my mother. Because of her illness, I became so empathetic to others. I have suffered so much that I become happy with good news. I think I am much more compassionate than before; watching a sad movie makes me move to tears ”. (C13).

In fact, the disease caused the family caregivers to become more sensitive to life events and react to small changes:

“ My sister’s illness has made it much easier for me to express my feelings than before. For example, if one of my stuttering students talks in full sentences without stutters, I will be so much happy and excited, so that even his mother will not show that much excitement” . (C6).

Being Stronger in the face of life problems

The problems raised by living with a schizophrenic patient strengthened the family caregivers’ self-confidence. They believed that these difficulties made them stronger so that they could handle other problems in life.

“Those hard days made me strong and impassive. As strong as iron in the face of these problems. When I encounter a problem, I consider it nothing compared to those hard days ”. (C15).

In case of family member’s disease, such as a spouse, hiring caregivers to carry the burden of life by accepting new roles and tasks is required. They experienced new situations throughout the care path, which made them more prepared for the future events.

“ When my husband got neurological disorders, I had to manage my children, so that I would not need anyone. So, I stayed as solid as a rock. And did not give up”. (C2).

Making greater intellectual developments than peers

Children of patients with schizophrenia were severely affected by the disease so that their needs are not met appropriately. Based on the children’s gender, some roles may be assigned to them, which enable them to reach intellectual maturity earlier than their peers.

“Comparing myself to my peers, I notice that I am more mature with than them regard to the surrounding issues. Sometimes, my friends tell me: ‘you are very wise and understand beyond your age”. (C11).

“ In other words, my mother’s disease helped my mind grow faster; that is, I became more mature”. (C12).

Being patient

One of the positive aspects of having a family member with schizophrenia was patience. In such families, patience resulted from caring for the patient is expanded through the life. A participant stated that she became much more patient in social interactions than the past and could tolerate inappropriate behavior of others much easier.

“ I became much more patient than before; struggling with him increased our endurance and patience more than before. I realized that my patience had increased in dealing with others”. (C5).

Participants noted that this patience was a reward from God. They got surprised that they had achieved such strength and endurance, as the result of peaceful behavior with the patient.

“ God has given me a patience; in my family, I am famous for being patient. Sometimes, I wonder how much patient I am. In dealing with my husband’s behaviors, I learned that I should be silent when he is angry ... this increased my patience”. (C10).

Having enhanced communication skills

The development of communication skills was one of the family’s achievements from living with schizophrenic patients, which was noted by participants, especially female caregivers. The illness of a family member, especially the spouse and father of the family, resulted in the loss or decrease of income . So, other family members, such as the patient’s spouse, were required to work outside the home to pay for the expenses. Outside jobs provided the opportunity for individuals to interact with many people from different social backgrounds and strengthened their communication skills.

“From the onset of my husband’s disease, I have been working in different people’s homes; for example, one was a doctor and one was a businessman. Every family was different and commuting to their homes helped me to learn how to speak well and communicate easily with others. As a result, I do not feel nervous while talking to others anymore”. (C2).

Achieving independence faster

Children of a parent with schizophrenia had to participate in household chores; they even needed to cooperate in caring for the patient. Such early cooperation and tasks allowed them to achieve independence sooner than their peers and strengthened their sense of responsibility.

“ I stood on my own two feet much earlier than my friends and became independent ... I kept the wolf from the door so that I do not put my burden on my siblings’ shoulder. In other words, my mother’s illness made me grow up. My life’s route was so that I had to grow up and become independent very quickly”. (C13).

Having increased ability to understand others

Incidence of the disease in a family exposed the family members to the judgments of others. Lack of understanding by others caused feelings such as sadness, embarrassment, and stigma in family members. Experience of these negative feelings caused the patient’s family caregivers to try to understand others in similar situations and avoid misjudgments because they have already been victims of negative perceptions of others.

“ This disease has taught me never to judge others and their lives or to make fun of anyone. This reminds me of my life, I know that judging and making fun of others can have harmful and negative consequences”. (C1).

Strengthening family ties

This category showed that when one family member had schizophrenia, the other family members got involved in caring for the patient to relieve the burden. As a result of this cooperation, the family ties strengthened.

Increasing dependence and affection among family members

The reaction of family members to the suffered member strengthened their love to each other. In present study, the father of a patient had a heart attack when his son was hospitalized in a psychiatric hospital. The presence of a disease in the family made the family members realize how much they loved each other.

“ Now, I understand how much my husband loves our children. When one of our children was hospitalized, my husband had a heart attack and was hospitalized too ..., for this reason, I love my husband more than before; I think we are closer than before ”. (C7).

Members of the patient’s family considered the illness as a common pain, which required empathy between family members, a feeling that brought family members together, and increased love between them.

“ My son’s illness has brought me and my husband closer. This pain has made us more dependent on each other to take care of our son ... Now my son is in a condition that we need to be more empathetic, and that is what happened” . (C9).

Developing family members’ empathetic participation in caring patient

The disability caused by schizophrenia may be so severe that the patient may not be able to perform personal daily tasks and hygiene self-care such as bathing, dressing, and eating, and need the help of others. When family members were aware of the patient’s disabilities and knew that no one could take care of the patient alone, they felt obligated to participate in housework and patient care.

“ From the onset of her disease, my husband cooperates in housework more ... For example, when my husband gets up early in the morning to go to work, he feeds her breakfast. He also helps me give her medications, take her to the doctor. Now, we are taking care of her together ”. (C8).

Participation in caring patient was not confined to family members, but also it can extend to married children who live separately and can cooperate with the family to reduce the stress and burden.

“ My brother and sister are married and do not live with us, but they still help us take care of my sister; they take her to the doctor, hospitalize her, and even pay for her hospitalization. They visit and help us more than before since my sister got ill” . (C6).

Increasing support among family members

Due to the lack of social support resources in Iran, families of patients with schizophrenia experience severe financial, emotional, and psychological stress. Experiences of family caregivers in present study showed that in such situations, family members provided the role of financial, emotional, and psychological support for the caregiver.

“Since my husband got sick, my children supported me so much. With their support, I was able to go to the university and get two bachelor’s degrees; my children helped me a lot ... my family also supported me and my children more than before”. (C10).

Supporting caring parents by family members helped them to adapt to the changes caused by schizophrenia.

“My children are very attentive to me, even my older children support their younger siblings more than before. My children’s support made me able to cope with my wife’s illness”. (C14).

Providing insight into the life

Based on the participants’ experiences, living with schizophrenia patients provided them insight into life. As a result of illness, they tried to change their attitude toward life, think deeply, and pay attention to what they had neglected before the illness.

Understanding the importance of mental health

The experience of families living with schizophrenics made them realize the importance of mental health in life and worry about their health. One of the causes of distress among caregivers was their qualifications to help the patient.

“ Since my brother became ill, I feared developing the disease. I was obsessed with it for a while, so I went to a psychiatrist and now I am under control. Because I know if I get sick, there is no one to take care of my brother; so, I considered my health”. (C3).

The positive and negative symptoms of schizophrenia patients and their destructive behaviors had destructive effects on the patient and caregivers. So, the participants tried to avoid what harms their mental health, such as getting upset and nervous. They avoided trivial issues and considered their mental health as one of the most important aspects of health that should be protected.

“ Since my sister became ill and I saw her behaviors, I realized that maintaining mental health is crucial. I am more concerned about my health and my children’s health. I try not to get upset by little things”. (C1).

Changing the mindset from comfort to peace in life

Losing family peace due to stressful factors caused by schizophrenia helped the participants to conclude that having peace in life was much more valuable than gaining wealth, facilities, and money. They believed that comfort was effective under the shadow of peace.

“ Even though I am old, the disease has changed my mindset. Previously I wanted my children to have good jobs and good incomes; that is to say, I was worried about their comfort. Now, I believe that peace in life is much more important than money”. (C9).

Participants stated that the presence of this disease changed their attitude towards life events; so, they tried to take life easier.

“ Now, I try to make the events easy, I think they are not worth being upset, I should not grieve for them and ruin my life, I can handle them”. (C12).

Feeling the presence of superior power in life

Spirituality and closeness to God were among the other positive experiences of family caregivers with a schizophrenic patient. Participants believed that taking care of the patient was a blessing in their life and a reward from God. In fact, they believed that God bestowed them rewards for taking care of a patient.

“ This is how God gives me sustenance. Since she is living with us, our sustenance has been growing. She has sustenance, when I take care of her, God gives me more sustenance. I do not mean the money, but the blessings”. (C8).

The presence of the disease led most family members to engage in religious activities and participate in religious ceremonies. They noted that this closeness to God was impacted by the illness of a family member since they felt God’s presence in their lives more than ever before.

“With my mother’s illness, I became much closer to God, which means I pray a lot. I vow and attend religious ceremonies. Maybe if my mother was not sick, I would not be so close to God. I feel God has taken my hand in some situations and helped me”. (C13 (.

Social mobility

As a result of the illness of a family member, especially the father or spouse, the family lost its social and economic position. The experiences of some participants showed that the family members tried to reach their previous social status, improve their social class, and build their lives.

A flip to change lifestyles

The suffering in caregivers’ life made them decide to change their lives, build their own lives, and compensate for the damage done to the family.

“When my husband fell ill, I said: ‘I cannot just sit around and do nothing. I have two children and I have to build my life.’ So, I started to change”. (C10).

The children of the patients were also determined to choose a good path in their lives. They tried to be beneficial to society; so, they had higher levels of motivation to study and find a suitable job.

“I got my diploma ... I went and bought an organ ... One day I came to myself and said: ‘what do you want to do?’ At that moment, I decided that I should change my life and serve the people around me ... I sold my organ and bought law books; I told myself that I must go to law school and I should be a member of the parliament in the future. Fortunately, I entered the university the same year”. (C11).

Acquiring and enhancing capabilities

The participants’ experiences showed that family members of patients decided to work harder to support themselves. As a result, they began to improve their previous skills or learn new ones based on their working situation. However, if the family head was not sick, they would never think about acquiring or improving their skills.

“ My husband’s illness has made me learn live my life. I know needlework; so I went to my mother’s house since she does needlework too... During this time, I saw different models and learned them; I did not know them before”. (C4).

To forget about the problems of living with the patient, some participants tried to entertain themselves with their favorite activities, such as exercising, sewing, going to university, etc. Such activities improved family members’ skills.

“ To entertain myself and forget about my sick husband, I was preoccupied with my favorite activities. I continued my studies, got a diploma, and then got two bachelor’s degrees. I started a sewing school, established a gym, and continued my favorite sport ...” (C10).

Economic dynamism

According to the participants’ experiences, family responsibilities led them to pursue income-generating activities; their efforts to support family expenses improved their economic conditions.

“ I could manage my life even better than when my husband was not sick. Thank God my income was not bad. I helped my daughter and son to get married. I work and pay for my husband’s expenses. Once a year, I hospitalize him”. (C2).

The experience of living with a patient with schizophrenia, which is a chronic and debilitating disorder, has taught the participants to manage their lives financially and provide themselves with the necessary welfare amenities. They learned not to wait for help from others. So, they performed income-generating activities.

“I have learned that I have to work and pay for my children anyway. To this end, I accept needlework orders. I have a little income, but it is better than before since I do not ask others for money”. (C4).

Dynamism in social services

According to the participants, dealing with the suffering of the disease and observing its negative effects made them move beyond the family conditions and decide to serve other people in the community.

“I sought to establish a charitable school on the outskirts of the city ... or I pursued a lot to get the privilege of a facilitation office there ... I owe all this success to the hardships I endured because of my father’s illness”. (C11).

The patient’s activities before the disease were a motivation for the participants to help others.

“ After my sister’s illness, when we saw that she could no longer go to the local mosque, my sister and I went there. When we do something for the people; well, God will take our hand. We could collect donations for the recent flood victims”. (C6).

According to the results, family caregivers of the patients with schizophrenia experienced positive consequences of taking care of the patient, which are a result of their struggle with this disease. The positive consequences included four categories included developing positive traits in family members, strengthening family ties, developing insight into life, and social mobility. Shiraishi and Reilly (2019) in a qualitative meta-summary, investigated the positive and negative consequences of schizophrenia in family caregivers. They concluded that family members of a person with schizophrenia experienced a series of traumatic events at the onset of the disease. Subsequently, they faced with a continuous cycle of care. In this cycle, they experienced negative effects of the disease, including insecurity, loss of life expectancy and health, decreased personal and social resources, stigma, etc. Experiences in these conditions led to the emergence of positive aspects of care and values such as family solidarity and personal growth [ 5 ]. Based on the participants’ experiences, the sufferings that families endure in taking care of the patient have led to positive consequences and changes in their lives.

In a study by Wiens and Daniluk (2017), mothers of children with schizophrenia experienced personal changes during child care. These positive changes included a deep sense of awareness of others’ needs and sensitivity, less judgment, and higher levels of compassion. They believed that dealing with the child’s illness increased their patience and endurance [ 27 ]. These results are consistent with those of present study on the development of positive personality traits. The results of some studies showed the presence of a schizophrenic patient in the family caused personal growth in the caregivers [ 28 , 29 , 30 , 31 ], which confirms the experiences of our participants. This growth is not a goal, but a response to what life is all about. In other words, this growth is a valuable part of the human experience that helps them cope with the ongoing challenges of life [ 32 ]. Increased self-confidence [ 31 , 33 , 34 ], easier expression of emotions [ 31 , 35 , 36 ], and increase of patience and tolerance [ 27 ] were positive consequences of the caregivers’ personal growth in various studies, which are consistent with the results of the present study.

Based on the participants’ experiences, strengthening family ties through family caregivers’ support, participation in caring patient, and increased love for each other were the family achievements in dealing with the disease. Some scientist (Mizuno et al. (2011), Barnable et al. (2006), Sethabouppha and Kane (2005), and Wiens and Daniluk (2009)) reported an increase in love and affection among family members after the incidence of the disease [ 27 , 29 , 36 , 37 ], which confirm results of the present study. An increase in family cohesion was also reported as positive experiences of the family members with schizophrenic patients in other studies [ 27 , 33 , 38 ], which are similar to the results of our study. When a family member develops schizophrenia, the difficulties caused by the disease may disrupt the family. If family members stay together and share care responsibilities, they become closer to each other and the primary caregiver feels less burden and becomes stronger [ 14 ].

Social mobility in terms of economic, social, and professional empowerment was another result of the present study. Furthermore, researchers in several studies reported that increased levels of knowledge and skills were the positive consequences of caring for a patient with schizophrenia [ 31 , 34 , 38 ]. In our study, participants tried to build their lives by learning new skills, upgrading their previous skills, and seeking to gain a better social and professional position.

The development of insight into life was another positive consequence of the disease mentioned by our participants. Chen et al. (2004) conducted a quantitative study and concluded that caregivers gained new insights into their lives in the process of caring for the patient with schizophrenia [ 14 ]. Some researchers (Sethabouppha and Kane (2005) and Wiens and Daniluk (2009)) indicated that unforeseen challenges of living with a patient led people to appreciate life more and perceive the meaning of love and affection better [ 27 , 36 ].

The results suggest that mental health professionals should help family caregivers decide to better respond to their challenging roles and increase their sense of accomplishment and personal growth. In the present study, we reported a set of care benefits for family caregivers that could be used as a theoretical method to design appropriate interventions for families and their patients. Interventions should target the use of internal resources and family abilities such as personal characteristics, family relationships, religion and spirituality, and socioeconomic integration of family members aimed at facilitating the process of living with schizophrenia patients. In this way, it is possible to cause positive changes for family caregivers and patients.

Participants had a variety of shared experiences of a positive life with schizophrenia patients and caring. However, each experience is unique, and each family caregiver could only understand the cultural and religious context in which he or she lives. Therefore, we suggest that health care interventions be appropriate to the religious, cultural and ethnic structure of the families to strengthen the internal strengths in the families of patients with schizophrenia. More detailed studies are recommended to evaluate the results of the present study in Iran and other cultures, and contexts and assess how the relationship between the patient’s recovery and positive outcomes perceived by family caregivers.

Limitations

The present study was performed in the southeast part of Iran, so the generalization to other cultural groups needs more studies in other cultural groups. Because families take care of patients at home, observing all behaviors of family members at the desired times was not possible. The researcher tried to control this limitation by long engaging with the family members and gaining their trust so that they could express their behaviors freely.

The present study provides some evidence about the positive consequences of living with a schizophrenic patient based on the experiences reported by caregivers. In fact, the challenges of life and family experiences in caring for the patient have led to positive changes in family perceptions. As a result, investigating valuable experiences of the family members in caring for the patient and examining their strengths can help the researchers to design and develop family interventions for better patient care.

Availability of data and materials

The transcripts from which this script was written are available on request from the corresponding author.

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Acknowledgments

We appreciate Kerman University of Medical Sciences for supporting this study and participants.

The study is funded by the Kerman University of Medical Sciences. The funding institution did not play part in designing, conducting the study, managing, collecting and analyzing data and making decision to submit the report of publication.

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Roghayeh Mehdipour- Rabori, Jamileh Farokhzadian, Esmat Nouhi & Sakineh Sabzevari

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SS and RM supervised the study. FD, SS and SN designed the study. RM and JF prepared the guide of the interview. FD conducted the interviews. FD, JF and SS analyzed the interviews. FD and SS drafted the manuscript. The entire team read and approved the final manuscript.

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Correspondence to Sakineh Sabzevari .

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The Ethics Committee of Kerman University of Medical Sciences approved this study with the code of IR.KMU.REC.1398.222. To conduct this study, the participants were initially provided with some explanations about the study goals and processes. All family caregivers signed written informed consent to participate in this study. The place, time, and duration of the interviews were selected based on the participants’ preferences. Before the interviews, participants’ consent for recording their interviews and taking notes from them was obtained. Participants were ensured about the confidentiality of all personal information. They were explained that all audio files were stored securely on password-protected servers by the first author and deleted after the final report. Participants could withdraw at any stage of the study.

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Darban, F., Mehdipour- Rabori, R., Farokhzadian, J. et al. Family achievements in struggling with schizophrenia: life experiences in a qualitative content analysis study in Iran. BMC Psychiatry 21 , 7 (2021). https://doi.org/10.1186/s12888-020-03025-w

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DOI : https://doi.org/10.1186/s12888-020-03025-w

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Case study: treatment-resistant schizophrenia

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Learning objectives

After reading this article, individuals should be able to:

• Describe the management of schizophrenia;
• Understand pharmaceutical issues that occur during treatment with antipsychotics, especially clozapine ;
• Explain how the Mental Health Act 1983 impacts on care;
• Understand the importance of multidisciplinary and patient-centred care in managing psychosis.

Around 0.5–0.7% of the UK population is living with schizophrenia. Of these individuals, up to one-third are classified as treatment-resistant. This is defined as schizophrenia that has not responded to two different antipsychotics ​[1,2]​ .

Clozapine is the most effective treatment for such patients ​[3]​ . It is recommended by the National Institute for Health and Care Excellence (NICE)[4], and is the only licensed medicine for this patient group ​[4,5]​ . For treatment-responsive patients, there should be a collaborative approach when choosing a treatment ​[4]​ . More information on the recognition and management of schizophrenia can be found in a previous article here , and in accompanying case studies  here . 

This case study aims to explore a patient’s journey in mental health services during a relapse of schizophrenia. It also aims to highlight good practice for communicating with patients with severe mental illness in all settings, and in explaining the role of clozapine. 

Case presentation

Mr AT is a male, aged 26 years, who has been diagnosed with paranoid schizophrenia. He moved to the UK with his family from overseas five years ago. He lives with his parents in a small flat in London. His mother calls the police after he goes missing, finding his past two months’ medication untouched. 

He is found at an airport, attempting to go through security without a ticket. He is confused and paranoid about the police asking him to come with them. 

He is taken to A&E and is medically cleared (see Box 1) ​[6]​ . 

Box 1: Common differentials for psychotic symptoms

Medical conditions can present as psychosis. These include:

• Intoxication/effects of drugs (cannabis, stimulants, opioids, corticosteroids);
• Cerebrovascular disease;
• Temporal lobe epilepsy.

Mr AT’s history is taken by a psychiatrist, and his crisis plan sought (as per NICE recommendations) but he does not have one ​[7]​ .

He has been under the care of mental health services for two years and disputes his diagnosis of paranoid schizophrenia. He was admitted to a psychiatric hospital 18 months ago where he was prescribed the antipsychotic amisulpride at 600mg daily. 

He is teetotal, smokes ten cigarettes a day and smokes cannabis every day. His BMI is 26 and he has hypercholesterolaemia (total cholesterol = 6.1mmol/L, reference range <5mmol/L) but all other tests are normal. 

He has no allergies. His only medication is amisulpride 600mg each morning, which he does not take. 

Medicines reconciliation

Mr AT is transferred to a psychiatric ward and placed under Section 2 of the Mental Health Act , allowing detention for up to 28 days for assessment and treatment (see Box 2).

Box 2: The Mental Health Act 1983

This legislation allows for the detention and treatment of patients with serious mental illness, where urgent care is required. This is often referred to as “sectioning”.

It includes regulations about treatment against a patient’s consent to safeguard patients’ liberty, which become more stringent with longer detentions.

Patients may only be given medication to treat their mental illness without their consent and may refuse physical health treatment. 

He denies any mental illness and tells the team they are conspiring with MI6. He is visibly experiencing auditory hallucinations: seen by him talking to himself and looking to empty corners of the room. Amisulpride is re-prescribed at 300mg, which he declines to take. 

A pharmacy technician completes a medicines reconciliation and contacts the care coordinator. The technician provides information about Mr AT’s treatment and feels he is still unwell as he has continued to express paranoid beliefs about his neighbours and MI6.

The ward pharmacist speaks to the patient. As per NICE guidance on medicines adherence , they adopt a non-judgemental attitude ​[8]​ . Mr AT is provided with information on the benefits and side effects of the medication and is asked open questions regarding his reluctance to take it. For more information on non-adherence to medicines and mental illness, see Box 3 ​[9]​ .

Box 3: Medicines adherence and mental health

Adherence to medication is similar for both physical and mental health medicines: only about 50% of patients are adherent. 

Side effects and lack of involvement in decision making often lead to poor adherence. 

In mental illness, other factors are: 

• Denial of illness (poor ‘insight’); 
• Lack of contact by services;
• Cultural factors, such as family, religious or personal beliefs around mental illness or medication.

Mr AT reports gynaecomastia and impotence, and says that he will not take any antipsychotics as they are “poison designed by MI6”, although is unable to concentrate on the discussion owing to hearing voices. 

He is prescribed clonazepam 1mg twice daily owing to his distress, which is to be reduced as treatment controls his psychosis. He is offered nicotine replacement therapy but decides to use an e-cigarette on the ward. 

He is unable to weigh up information to make decisions owing to his chaotic thinking and is felt to not have capacity to make decisions on his treatment. The team debates what treatment to offer.

Patient preference

Mr AT refuses all options presented to him. A decision is made to administer against his will and aripiprazole is chosen as it is less likely to cause hyperprolactinaemia and sexual dysfunction. He then agrees to take tablets “if it will get me out of hospital”. 

After eight weeks of treatment with orodispersible aripiprazole 15mg, Mr AT is able have a more coherent conversation, but is hallucinating and distressed. He is clearly under treated. The pharmacist attempts to complete a side-effect rating scale ( Glasgow Antipsychotic Side-effect Scale [GASS] ) but he declines. He is pacing around the ward in circles: it is felt he may be experiencing akathisia (restlessness) — a common side effect of antipsychotics (see  Table 1 ). 

Treatment review

The team feels clozapine is the best option owing to the treatment failure of two antipsychotics.  

The team suggests this to Mr AT. He refuses, stating the ward is experimenting on him with new medication and he refuses to take another antipsychotics. 

The pharmacist meets the patient with an occupational therapist to discuss what his goals are. Mr AT states he wants to go to college to become a carpenter. They discuss routes to achieve this, which all involve the first step of leaving hospital and the conclusion that clozapine is the best way to achieve this. The pharmacist clarifies the patient’s aripiprazole will not continue once clozapine is established. They leave information about clozapine with the patient and offer to return to discuss it further. 

Mr AT agrees to take clozapine a week later (see Box 4) ​[10–14]​ . Aripiprazole is tapered and stopped.

Box 4: Clozapine characteristics

Clozapine significantly prolongs life and improves quality of life ​[10]​ . Delaying clozapine is associated with poorer outcomes for patients ​[11]​ . 

Clozapine is under-prescribed owing to healthcare professionals’ anxiety and unfamiliarity around its use ​[12–14]​ .

It causes neutropenia in up to 3% of patients so regular monitoring is required . Twice-weekly monitoring is needed if neutrophils are <2 x10 9 /L. Most patients should stop clozapine if neutrophils are <1.5×10 9 /L. These ranges can differ from some laboratory definitions of neutropenia. 

Other side effects include sedation, hypersalivation and weight gain. See  Table 2  for red flags for serious side effects. 

Clozapine is titrated up slowly to avoid cardiovascular complications. A treatment break of >48 hours warrants specialist advice for a retitration plan. 

The pharmacist meets with Mr AT to discuss clozapine. He is told that this is likely to be a long-term treatment. The pharmacist acknowledges that the patient disagrees with his diagnosis, but this treatment is likely to prevent him from returning to hospital. 

He is started on clozapine at 12.5mg at night, which is slowly increased. Pre- and post-dose monitoring of his vital signs is completed. 

On day nine of the titration, his pulse is 115bpm. He otherwise feels well and blood tests show no signs of myocarditis (see   Table 2), so the titration is continued but slowed.

After 3 weeks he is taking 150mg twice daily of clozapine and his symptoms have significantly improved: he is regularly bathing, not visibly hallucinating and engaging with staff.

The pharmacy technician completes a GASS form. Mr AT reports constipation, hypersalivation and sedation. 

A pharmacist meets the patient to reiterate important counselling points, and discuss questions he may have about his treatment and how to manage side effects. Medication changes are made with the patients’ input: 

• His constipation is monitored with a stool chart and he is started on senna 15mg at night;
• He is started on hyoscine hydrobromide 300 micrograms at night for salivation;
• He is switched to clozapine 300mg once daily at night to simplify his regime and reduce daytime sedation. His clonazepam is reduced and stopped.

Smoking is discussed owing to tobacco’s role as an enzyme inducer (more information on tobacco smoking and its potential drug interactions can be found in a previous article here ). Mr AT states he will continue to use an e-cigarette for now. He is informed that if he starts smoking again, his clozapine may become less effective and he should immediately inform his team. 

He is discharged a few weeks later via a home treatment team and attends a clinic once weekly. On each attendance, he has a full blood count taken and analysed on site. He is assessed by a pharmacy technician and nurse for side effects and adherence to treatment, and his smoking status is clarified. 

The technician asks what he thinks the clozapine has done for him. Mr AT states he is still unsure about having a mental illness, but recognises that clozapine has helped him out of hospital and intends to continue taking it. 

Good practice in the pharmaceutical care of psychosis involves:

• Active patient involvement in discussions on treatment decisions;
• Regular review of treatment: discussing efficacy, side effects and the patient’s view and understanding of treatment; 
• Multidisciplinary approaches to helping patients choose treatment;
• For patients who dispute their diagnosis and the need for treatment, open dialogue is important. Such discussions should involve the patient’s goals, which are likely to be shared by the team (rapid discharge, preventing admissions, reducing distress); 
• Information about treatment should be provided regularly in both written and verbal form;
• Where appropriate, involve carers/next of kin in decision making and information sharing. 

Important points

• Schizophrenia affects 1 in 200 people, meaning such patients will present regularly in all settings;
• Patients with acute psychosis, who are in recovery, may be managed by specialist teams, who are the best source of information for a patient’s care;
• Collaborating with the patient on a viable long-term treatment plan improves adherence;
• Clozapine is recommended where two antipsychotics have failed;
• Clozapine is a high-risk medicine, but the risks are manageable;
• Hydrocarbons produced by smoking (but not nicotine replacement therapy, e-cigarettes or chewing tobacco) induce the enzyme CYP1A2, which reduces clozapine levels markedly (up to 20–60%). Starting or stopping smoking could precipitate relapse or induce toxicity, respectively.
• 1 Conley RR, Kelly DL. Management of treatment resistance in schizophrenia. Biological Psychiatry. 2001; 50 :898–911. doi: 10.1016/s0006-3223(01)01271-9
• 2 Gillespie AL, Samanaite R, Mill J, et al. Is treatment-resistant schizophrenia categorically distinct from treatment-responsive schizophrenia? a systematic review. BMC Psychiatry. 2017; 17 . doi: 10.1186/s12888-016-1177-y
• 3 Taylor DM. Clozapine for Treatment-Resistant Schizophrenia: Still the Gold Standard? CNS Drugs. 2017; 31 :177–80. doi: 10.1007/s40263-017-0411-6
• 4 Psychosis and schizophrenia in adults: prevention and management. NICE. 2014. https://www.nice.org.uk/guidance/cg178/ (accessed Jan 2022).
• 5 Clozaril 25 mg tablets. Electronic medicines compendium. 2020. https://www.medicines.org.uk/emc/product/4411/smpc (accessed Jan 2022).
• 6 Psychosis and schizophrenia: what else might it be? NICE. 2020. https://cks.nice.org.uk/topics/psychosis-schizophrenia/diagnosis/differential-diagnosis/ (accessed Jan 2022).
• 7 Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services. NICE. 2011. https://www.nice.org.uk/guidance/cg136/ (accessed Jan 2022).
• 8 Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence . NICE. 2009. https://www.nice.org.uk/guidance/cg76/ (accessed Jan 2022).
• 9 Taylor D, Barnes T, Young A. The Maudsley Prescribing Guidelines in Psychiatry . 13th ed. Hoboken, New Jersey: : Wiley 2018.
• 10 Meltzer HY, Burnett S, Bastani B, et al. Effects of Six Months of Clozapine Treatment on the Quality of Life of Chronic Schizophrenic Patients. PS. 1990; 41 :892–7. doi: 10.1176/ps.41.8.892
• 11 Üçok A, Çikrikçili U, Karabulut S, et al. Delayed initiation of clozapine may be related to poor response in treatment-resistant schizophrenia. International Clinical Psychopharmacology. 2015; 30 :290–5. doi: 10.1097/yic.0000000000000086
• 12 Whiskey E, Barnard A, Oloyede E, et al. An Evaluation of the Variation and Underuse of Clozapine in the United Kingdom. SSRN Journal. 2020. doi: 10.2139/ssrn.3716864
• 13 Nielsen J, Dahm M, Lublin H, et al. Psychiatrists’ attitude towards and knowledge of clozapine treatment. J Psychopharmacol. 2009; 24 :965–71. doi: 10.1177/0269881108100320
• 14 Verdoux H, Quiles C, Bachmann CJ, et al. Prescriber and institutional barriers and facilitators of clozapine use: A systematic review. Schizophrenia Research. 2018; 201 :10–9. doi: 10.1016/j.schres.2018.05.046
• This article was corrected on 31 January 2022 to clarify that tobacco is an enzyme inducer, not an enzyme inhibitor

Useful structured introduction to the subject for clinical purposes

Thank you Amrit for your feedback, we are pleased that you found this article useful.

Michael Dowdall, Executive Editor, Research & Learning

Please note that smoking causes enzyme INDUCTION not INHIBITION as stated. (Via aromatic polyhydrocarbons, not nicotine)

Hi James. Thank you for bringing this to our attention. This has now been corrected. Hannah Krol, Deputy Chief Subeditor

Only with Herbal formula I was able to cure my schizophrenia Illness with the product I purchase from Dr Sims Gomez Herbs A Clinic in South Africa

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Case Reports in Schizophrenia and Psychotic Disorders: 2023

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• Published: 22 August 2024

Long-term clinical recovery and treatment resistance in first-episode psychosis: a 10-year follow-up study

• Kristin Fjelnseth Wold   ORCID: orcid.org/0000-0003-4445-6010 1 , 2 ,
• Isabel Viola Kreis   ORCID: orcid.org/0000-0002-1022-699X 1 ,
• Gina Åsbø 2 , 3 ,
• Camilla Bärthel Flaaten 2 ,
• Line Widing 1 , 4 ,
• Magnus Johan Engen   ORCID: orcid.org/0000-0001-5080-7011 5 ,
• Siv Hege Lyngstad 5 ,
• Erik Johnsen 6 , 7 ,
• Torill Ueland 2 , 3 ,
• Carmen Simonsen 3 , 8 &
• Ingrid Melle   ORCID: orcid.org/0000-0002-9783-548X 1 , 2  

Schizophrenia volume  10 , Article number:  69 ( 2024 ) Cite this article

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• Psychiatric disorders

Illness trajectories in people with first-episode psychosis (FEP) vary significantly over time. Identifying early-course parameters predicting outcomes is essential, but long-term data still needs to be provided. We conducted a 10-year follow-up study of a comprehensive first-episode psychosis (FEP) cohort investigating the prevalence of clinical recovery (CR) and treatment resistance (TR) after ten years, as well as clinical, demographic, and pre-illness predictors of long-term outcomes. 102 participants with FEP DSM-IV Schizophrenia spectrum disorders were recruited within their first year of treatment. The Treatment Response and Resistance in Psychosis Working Group (TRRIP) and the Remission in Schizophrenia Working Group (RSWG) criteria were used to define TR and CR, respectively. At 10-year follow-up, 29 (29%) of the participants were classified as in CR, while 32 (31%) were classified as TR. We also identified a larger middle group ( n  = 41, 40%) consisting of participants in partial recovery. 7% of all participants had tried Clozapine at the 10-year follow-up. Logistic regression analyses identified insidious onset (OR = 4.16) and baseline disorganized symptoms (OR = 2.96) as significantly associated with an increased risk of developing TR. Good premorbid academic adjustment (OR = 1.60) and acute onset (OR = 3.40) were associated with an increased chance of CR. We identified three long-term outcome groups by using recent consensus definitions. We also identified the potential importance of assessing baseline disorganized symptoms and monitoring patients with insidious onset more closely. Further, the findings suggest that clinicians should pay close attention to early-course parameters and provide adequate treatment to improve long-term outcomes of FEP.

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Introduction.

The clinical course of first-episode psychosis (FEP) varies significantly, ranging from severe, long-term illness to complete recovery 1 , 2 . This variability is reflected in the fluctuation of symptoms and dysfunction over time and patient groups, emphasizing the importance of early identification of patients who differ in their treatment needs 3 , 4 .

Symptoms observed during the first 2−3 years after illness onset significantly impact long-term prognosis 5 , 6 , and some studies suggest that early course parameters, both pre-treatment and within the first year, are significant predictors of long-term outcomes 6 , 7 . Despite a substantial body of literature exploring predictors of treatment response during the early stages of psychosis 8 , 9 , 10 , the impact of early treatment response on long-term outcomes has not been thoroughly studied 7 , 11 , 12 , 13 . Previous research on long-term outcomes of psychotic disorders has often included cohorts of existing, multi-episode patients, which could enrich the sample with patients with unfavorable outcomes, thus distorting our conception of prognosis 12 .

The most common definition of clinical recovery (CR) is based on meeting the criteria for clinical remission suggested by the Remission in Schizophrenia Working Group (RSWG) 14 , along with an additional requirement of functional improvement 15 , 16 , 17 . A subgroup of FEP patients experiences CR early in the course of illness. Existing reviews of CR prevalence 1 , 8 , 18 have included studies with diverse patient samples and follow-up periods, making it difficult to obtain reliable CR rates for FEP. However, a handful of long-term follow-up studies of FEP samples have shown CR rates ranging from 14 to 38% 1 , 7 , 12 , 19 , 20 , 21 . The most recent meta-analysis found a ∼ 21% recovery rate across 26 studies 22 .

Identifying long-term predictors of CR is difficult due to the use of varying definitions of recovery and other methodological differences across long-term studies 16 . Catalan and colleagues conducted a comprehensive systematic review and meta-analysis involving over 100 articles without finding any socio-demographic or clinical predictors of CR 23 . In another recent review and meta-analysis, Hansen and colleagues found no study characteristics or differences in intervention services that affected recovery rates 22 . However, a report from the comprehensive OPUS study found that lower severity of negative symptoms at baseline and earlier age at first diagnosis predicted higher recovery rates at ten years 20 .

Another group of patients does not appear to benefit from antipsychotic (AP) treatments and is thus classified as treatment-resistant (TR). The most common definition of TR suggested by the Treatment Response and Resistance in Psychosis (TRRIP) Working Group defines TR as a sustained lack of remission with persistent functional loss in the context of two adequate trials of different AP, or the use of clozapine 24 . Recent meta-analyses suggest that approximately one-third of all FEP patients will exhibit TR 11 , 25 , 26 . TR is associated with inferior clinical outcomes, a poor quality of life, more healthcare usage, and higher societal costs, and presents a major therapeutic challenge 26 , 27 . While well-suited for clinical trials, it is still unclear to what extent the TRRIP criteria are useful in everyday clinical practice 10 , 28 .

The only currently available treatment for TR patients is clozapine 29 , with some indications of additional benefit from specific psychosocial treatments 30 . There are also indications that earlier intervention for TR could reduce long-term illness severity 3 , 24 , 25 , 31 , 32 , 33 , as suggested by signs of a critical time window for optimal effect of clozapine 31 , 33 , 34 . Clozapine is, however, either not used at all or underused 35 , and the start of clozapine treatment is often substantially delayed 28 . Clozapine is not effective for all TR patients 36 , and we have no biomarkers with adequate reproducibility or enough predictive accuracy to assess which patients will respond to clozapine 37 .

Previous studies in FEP have identified a younger age at onset 38 , 39 , 40 , lower pre-onset educational attainment 40 , poorer premorbid adjustment 2 , 7 , male gender, being single 40 , longer duration of untreated psychosis (DUP) 7 , 39 , higher levels of baseline positive- 40 and negative symptoms 39 , concurrent substance use 2 , 39 , poor initial treatment response 7 , and a baseline schizophrenia diagnosis as significant predictors of a general poor outcome in FEP 7 , 40 . One previous study has also found baseline disorganization as predictive of TR 28 . At the individual level, few predictive factors have shown enough specificity to be clinically useful. There are most probably also distinct predictors of different outcome dimensions. In the OPUS study, Austin and colleagues found that longer DUP and substance abuse were associated with poorer positive symptom trajectories, while poor social functioning, disorganized symptoms, and a baseline schizophrenia diagnosis were associated with poorer negative symptom trajectories 41 .

To fully explore the impact of early predictors on long-term course and outcome, we need comprehensive, long-term follow-up studies of close to epidemiological FEP samples or unselected samples of incident cases with psychotic disorders. Despite their potential importance, such studies remain scarce.

In the current study, we aimed to:

Investigate the prevalence of CR and TR at 10-year follow-up in a comprehensive and unselected FEP sample.

Investigate pre-illness, demographic, and early clinical predictors of long-term outcomes (i.e., the rates of CR and TR after ten years of treatment).

Setting and participants

The current study has a prospective longitudinal observational design, using data from baseline, one-year, and ten-year follow-up of the FEP cohort in the ongoing Thematically Organized Psychosis Research study (TOP) at the Norwegian Centre for Mental Disorders Research (NORMENT). Participants between 18 and 65 years were recruited from inpatient and outpatient psychiatric units from the major hospitals in the Oslo area between 2002 and 2019. The hospitals’ catchment area covers approximately 660,000 inhabitants, serving 88% of Oslo’s total population.

Participants eligible for the prospective FEP study met DSM-IV criteria for schizophrenia, schizophreniform disorder, schizoaffective disorder, and psychotic disorder not otherwise specified (NOS) at baseline. They were recruited during their first year of treatment. They had not previously received adequate psychosis treatment, defined as hospitalization for treatment (not only observation) at a psychosis unit or treatment with adequate antipsychotic medication for ≥12 weeks or until remission. Due to the high prevalence of substance use in FEP, we included participants both with and without the use of illicit substances. Participants with a diagnosis of substance-induced psychotic disorders were excluded. Other exclusion criteria were severe brain injury, not speaking a Scandinavian language, and the presence of pronounced intellectual impairment (IQ below 70).

A total of 307 participants completed baseline clinical assessments and were eligible for participation in follow-up assessments. After 10 years, 102 participants completed assessments, i.e., a retention rate of ∼ 35% of living participants (14 participants had died). A subsample ( n  = 56) had participated in sub-studies that included a one-year follow-up and thus had data on one-year outcomes. Analyses showed no significant differences in gender, age, premorbid adjustment, DUP, baseline diagnosis, - global functioning, and -symptoms, or drug/alcohol use between completers and non-completers of the 10-year follow-up (10Y FU). We additionally extracted data from the National Health Registry for all baseline participants on treatment periods for mental disorders in the specialized health services as a proxy for illness severity. We found no significant differences in contacts with specialized healthcare services in the follow-up period (See Supplementary Fig. S1 and Tables S1 and S2 for an overview of attrition and comparisons between completers and no-completers).

The study methods comply with the Strengthening the Reporting of Observational Studies in Epidemiology checklist 42 . The study was conducted in accordance with the Helsinki Declaration. The participants provided written informed consent to participate at baseline and follow-up, and the study was approved by the Regional Committee for Medical and Health Research Ethics in Norway (REK #22265 & #2009-2485).

Clinical assessment

Trained clinical psychologists and medical doctors or psychiatrists carried out comprehensive clinical assessments, which took place over several face-to-face meetings at baseline, one- and 10-year follow-ups. Diagnoses were established using the Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I), modules A-E 43 , 44 at all time points. The clinical assessors were trained in reliable diagnostic practice according to a program developed at UCLA 45 . Within the TOP study, overall kappa scores ranged between 0.92 and 0.99 across different assessment teams 46 . We also collected information on treatment from medical charts, blood samples, and information on treatment history, education, occupation, and marital status.

Symptoms at baseline, one- and ten-year follow-up were measured with the structured clinical interview version of the Positive and Negative Syndrome Scale (SCI-PANSS) 47 . We grouped symptoms according to the Wallwork five-factor model, which consists of a subset of items constituting positive, negative, disorganized, excited, and depressive symptoms 48 . The Wallwork model is considered more appropriate for assessing symptoms within FEP populations 48 , 49 , 50 .

We used the Premorbid Adjustment Scale (PAS) 51 to measure premorbid social and academic functioning. This clinician-rated scale assesses social and academic performance with two separate subscales, each applied to different phases of life grouped by age. The poorest adjustment has the highest scores. We used the premorbid childhood phase subscales (0−11 years of age) to ensure that PAS scores did not overlap with any prodromal period preceding the first illness episode.

DUP was first determined at baseline and quantified in weeks from the onset of the first psychotic episode (defined by having a score of ≥4 on the PANSS items P1, P3, P5, P6, or G9 persisting for more than one week) to the commencement of adequate treatment 52 .

Mode of onset

Mode of onset was evaluated as insidious or acute, based on whether the first psychotic episode evolved from normal functioning to a full psychotic episode in more or less than 6 months, respectively 12 .

Functional assessment

The participants were assessed using the Global Functioning Scale (GFS) 53 , a text-revised, two-part scale (split for level of functioning and symptom burden) 54 . Participants with GFS scores of >= 61 at the one-year or ten-year follow-up were considered to be functionally recovered 20 , 55 . A GFS score of >= 61 indicates that the participant takes care of basic needs, lives independently, is employed, and maintains meaningful social relationships 53 .

Outcome groups

Ten-year outcome.

We identified participants meeting the TRRIP criteria for TR and the RSWG criteria for CR 10 , 14 , 24 . The TRRIP criteria define TR as the presence of symptoms of at least moderate severity (i.e., PANSS item scores >3) and a concurrent moderate level of functional impairment (i.e., GFS scores <= 60) for a duration of at least 12 weeks while using an AP at an effective dosage, within the context of at least two prior treatment trials, each lasting more than six weeks and involving an adequate dosage of two different APs, or the use of clozapine (Table 1 ). The RSWG-based criteria define CR as symptom remission for more than 24 weeks in the context of regained functioning (i.e., GFS scores >= 61). Participants who did not meet the TR or CR criteria were defined as belonging to the heterogeneous middle (HM) outcome group.

Following the recommendations outlined in the relevant national guideline 56 , we defined an adequate treatment trial as using at least one defined daily dosage of APs 57 for a minimum duration of two weeks or the use of clozapine. The original TRRIP definition of sufficient dosages is higher than the recommended dosage for FEP patients in the guidelines due to a better FEP response to AP 58 .

One-year sub-sample outcome

We have previously reported on one-year outcomes in a partly overlapping sample. Here we argued that only some FEP patients would have had the time to carry out two adequate trials of APs over the first year of treatment and outcome was at this point thus based on adaptations 10 of the standard criteria 24 : Early TR was here defined as not meeting remission criteria for at least 12 weeks in the context of continuing functional loss defined as a GFS score <61 14 (Table 1 ), Early CR was defined as meeting RSWG criteria for remission in the context of a GFS score >= 61. We used a time criterion of 12 weeks to ensure minimum stability.

Statistical analyses

We used the TSD (Tjeneste for Sensitive Data) facilities at the University of Oslo for safe data storage, The Statistical Package for the Social Sciences for Windows, Version 29.0, and the statistical programming language R for statistical analyses. All testing was conducted with a two-tailed significance level of 0.05. Data were checked for normality, homogeneity of variance, and outliers. Non-normally distributed variables were log-transformed before being included in further analyses.

We examined differences between the CR, HM, and TR groups at 10Y FU for premorbid, sociodemographic, and clinical variables with Chi-Square tests for categorical variables and ANOVAs with Tukey post hoc tests for continuous variables. Kruskal-Wallis tests were performed for non-parametric continuous variables.

After initial analyses, we conducted a series of multivariate binary and multinomial logistic regression analyses to identify predictors of long-term outcomes. The predictor variables were tested in advance to verify the absence of violations of the multicollinearity assumptions. The PAS subscales were highly intercorrelated, and we chose the scale that differed most between outcome groups in each analysis. The PANSS symptom dimension scales were also highly correlated, and we chose the scale with the most significant contribution to the model (i.e., disorganized symptoms). We used a likelihood ratio test to test the proportional odds and parallel regression assumptions. All significant variables from the initial analyses were included in the regression analyses, but only statistically significant factors that improved model fit were kept for further analyses, using -2 Log Likelihood and Akaike Information Criteria (AIC) to assess and compare model fit.

To identify predictors of CR and TR, we found that a binary logistic regression analysis had a better fit than a multinomial analysis for the data, most probably because of the heterogeneity of the middle group. For binary logistic analyses, each outcome was fitted separately in logistic regression: TR vs no-TR (i.e., reference group) and CR vs no-CR (i.e., reference group). In follow-up analyses, we also re-ran all analyses on the subset of participants who already met the diagnostic criteria for schizophrenia at baseline.

TR and CR at 10-year follow-up and their statistically significant predictors

Of 102 participants, 29 (28%) could be classified as CR and 32 (31%) as TR at 10Y FU. The heterogeneous middle group (HM) ( n  = 41, 40%) consisted of participants with partial recovery, participants with remitting/relapsing symptom patterns, and participants who met the clinical criteria for TR but not the full TRRIP criteria because they had not received two adequate treatment trials.

Table 2 presents the demographic and baseline clinical characteristics of the outcome groups. Table 3 presents 10-year follow-up data for the outcome groups.

There were statistically significant differences between the outcome groups at baseline in premorbid academic adjustment, DUP, age, global functioning, current relationship status, negative and disorganized symptoms, and alcohol use. The CR group had significantly better premorbid academic functioning, shorter DUP, and included more participants who were in a relationship than the TR group. The CR and HM groups had better baseline global functioning and fewer baseline negative and disorganized symptoms than the TR group.

The multivariate binary logistic regression analysis of TR versus no-TR (Table 4a ) indicated that an insidious onset of psychosis (OR = 4.16), more baseline disorganized symptoms (OR = 2.96), and a baseline schizophrenia diagnosis (OR = 6.04) had statistically significant contributions to the predicted outcome group membership at 10Y FU (2LL = 84.194, χ 2  = 35.00, df. = 3, p  < 0.001) and thus were independently associated with increased odds of belonging to the TR group. When analysing the subsample with a baseline schizophrenia diagnosis, insidious onset was still independently associated with increased odds of belonging to the TR group (OR = 4.65).

The binary logistic regression analysis of CR versus no-CR (Table 4b ) indicated that an acute onset (OR = 3.40), good premorbid academic adjustment (OR = 1.60) and not having a baseline schizophrenia diagnosis (OR = 5.02) had statistically significant independent contributions to belonging to the CR group at 10-year follow-up (2LL = 90.05, χ 2  = 21.31, df. = 3, p  < 0.001). When analysing the subsample, meeting the diagnostic criteria for schizophrenia at baseline, none of the predictors remained significant, most probably because of a lack of statistical power since only 5 participants met CR criteria.

The HM group comprised diverse outcomes. Seven participants (17% of HM) were continuously psychotic through the entire follow-up period, and 11 (27% of HM) met the clinical TRRIP criteria but not the full criteria. A total of 28 (68% of HM) met the RSWG remission criteria at the 10Y FU. Seven of these (17.5%) did not meet the time criterion and were thus less stable than required, while 21 (52.5%) had not achieved adequate levels of functioning. Finally, one participant (2.5%) had adequate levels of functioning but was not in symptomatic remission.

At the 10Y FU, seven (7%) participants of the 102 had tried Clozapine. All participants who used Clozapine were classified as TR patients and constituted 22% of the study’s TR group. It is practically possible that patients with good clozapine response could also be classified as recovered, but this was not the case in the current sample. In the 10Y FU period, the rate of participants using clozapine went up from ~2% (4/207) at one year to ~7% (7/102) after 10 years. The 17 (53%) of the TR participants and 7 (17%) of the HM group that were continuously psychotic from baseline to follow-up did not receive a clozapine trial.

At the 10-year follow-up, 78% of the TR group and approx. 50% of both the CR and HM groups were treated with standard APs. As required by the criteria, all TR participants had at least two adequate treatment trials, a total of 38% had three adequate trials, and 22% had four adequate trials of standard APs. In the CR group, 55% had at least two adequate trials, 19% had three trials, 12% had four trials, and one participant had a fifth AP trial (Table 5 ). There was also a significant difference in duration of hospitalization between the outcome groups at 10-year follow-up, where the TR group had significantly longer in-patient treatment compared to the CR and HM group (Table 5 ).

One-year outcome subsample analyses

A subsample of 57 participants also had available one-year data. A table analysis showed that 50% of those categorized as CR and 53% of those categorized as TR at 10 y FU, were already classified as such after one year of treatment (χ 24  = 10.69, p  = 0.030) (Table 6 ).

Treatment resistance and clinical recovery at 10-year follow-up

The current study has confirmed previous research findings that the long-term outcome of FEP varies considerably. By using established consensus definitions 14 , 24 , we identified three outcome groups after 10Y FU: CR (28%), TR (31%), and a heterogeneous middle outcome group (40%). The prevalence of CR and TR aligns with earlier findings 59 , 60 .

Predictors of TR and CR

We identified baseline disorganized symptoms, insidious illness onset, and having a baseline schizophrenia diagnosis as independent predictors of TR at the 10Y FU of FEP. Disorganized symptoms are often classified as reality distortion (positive) symptoms by many rating scales, including the original three-factor version of the PANSS. However, disorganized symptoms cover aspects of formal thought disorder, inappropriate affect, and bizarre behavior. Formal thought disorder has historically been considered one of the key features of schizophrenia 61 , and studies suggest that high levels of disorganized symptoms are indicators of transition to psychosis in high-risk populations 62 and possible indicators of TR in multi-episode patients 63 . Disorganized symptoms have also been found to be associated with poorer negative symptom trajectories in longitudinal studies 41 . We here show that baseline disorganized symptoms significantly predict long-term TR in a FEP cohort. Ortiz et al 63 . showed that pronounced levels of disorganized symptoms were easily identifiable in clinical practice, they can thus be a feasible indicator of identifying FEP at high risk of TR. A study showing that disorganized behavior and cognitive dysfunction can increase the risk of rejection from staff working with poor-outcome patients 64 emphasizes the importance of recognizing their clinical importance.

The finding that a baseline diagnosis of schizophrenia is a strong predictor of TR in FEP may appear self-evident. A more interesting clinical question is which aspects of the diagnosis are associated with the outcomes. We here found that baseline disorganized symptoms and an insidious onset of illness were characteristics that predicted TR at 10Y FU also after controlling for diagnosis. Insidious onset is a well-known predictor of poor outcomes in psychosis 65 , and a previous study of selected multi-episode patients reports a high proportion of insidious onsets in TR patients. Still, it has not previously been reported as a predictor of TR in FEP. Since the phenomenon is easily recognizable in clinical interviews, it can also be used to identify patients at high risk for TR in clinical settings.

The main predictors of CR are the absence of TR predictors, i.e., not having a baseline schizophrenia diagnosis and a more acute onset of illness, in addition to better premorbid academic adjustment. These findings align with findings from previous studies 23 , 63 and point to the importance of the early phases of illness for longer-term outcomes 31 . The finding that 50% of participants classified as in early CR or TR after one year of treatment meet the respective criteria for CR and TR also after 10 years aligns with this. Also, the finding of the predictive value of good premorbid academic adjustment aligns with a previous study finding that poor premorbid social adjustment predicted treatment resistance 66 .

Other studies have identified male gender as a predictor of poor outcomes, and we have in our previous report from the one-year follow-up that males were at higher risk of early TR 10 . Despite the fact that almost 70% of the TR group at 10Y FU were males, gender showed no significant predictive power. Some researchers have argued that female and male patients have the same number of lifetime readmissions, similar recovery rates, and similar functional outcomes 10 years after a first psychotic episode 67 . Although male participants may initially present with a more severe clinical picture, this does not appear to result in a more unfavourable long-term outcome 67 , 68 .

The heterogeneous outcome of FEP and the role of treatment

The largest patient group did not meet the criteria for TR or CR. This subgroup consisted partly of patients with poor symptomatic and functional outcomes that had not received enough adequate treatment trials and could thus not be classified as TR. This is not merely a classification problem but also a clinical problem because these patients most likely needed other treatment approaches than those they received, including receiving potential benefit from a clozapine trial. The findings also illustrate that while the TRIPP consensus criteria are well-suited for clinical trials, they most likely underestimate the prevalence of TR in observational clinical samples. Based on a one-year follow-up, we suggested that a longer observation period was needed to apply the “adequate treatment” part of the TRRIP consensus criteria in a valid way 10 , but observing the same phenomenon at ten years points to other mechanisms. It is of concern that clinicians do not appear to follow treatment guidelines 69 , 70 . There are indications that patients of clinicians with better adherence to guidelines have longer work hours, implying better functioning and capacity to work 71 .

There was also a group of patients within the HM group who met the RSWG remission criteria at the 10Y FU but was either less stable than required or had not achieved adequate levels of functioning. We have previously discussed whether the functioning criteria for recovery are too strict and that more reasonable criteria for functioning, in line with the general population, should be considered 16 , as well as offering other definitions of positive outcomes showing the possibility to have a good life despite experiencing psychosis 72 . There is also a possibility that our results indicate the need for more functionally focused treatment interventions and that our findings reflect a lack of such in the last ten years.

The use of clozapine in the study was low. This is problematic in light of recent findings of a possible critical time window for initiating clozapine treatment 37 and that delayed use may lead to poorer outcomes 33 . Others have also found that clozapine might be superior to other antipsychotics for achieving employment in TR patients 73 . It also indicates that using clozapine as a proxy for TR in observational studies will seriously underestimate the TR prevalence. It has been well documented that prescribing clinicians often underutilize clozapine 26 , 74 , 75 . Instead, a substantial number of TR patients may be exposed to unnecessary high doses of APs or polypharmacy approaches without a robust evidence-base 69 , 74 , 76 . Recent studies show that in addition to clozapine, specific tertiary care approaches and the addition of psychosocial interventions may be helpful 69 , 70 .

Strengths and limitations

This study has several strengths. Firstly, it reports on, considering the incidence rate, a large sample of individuals with FEP, continuously recruited from a broad catchment area served by a public health system that ensures access for all, irrespective of socioeconomic status and with long experience in handling patients from different cultures 77 . Ethnic minorities represented 16,7% of the sample, which is slightly less than percentage of ethnic minorities in the Oslo area (18%) 4 , but still within a representable range. This aspect aids in maintaining the representativeness of the study sample. Secondly, the study is based on a comprehensive clinical characterization using consensus criteria for relevant outcomes, with a long follow-up period 12 , 60 . Also, by including broad schizophrenia spectrum diagnoses at baseline, we acknowledge the diagnostic instability evident in the early stages of FEP. Thus, we believe we have a more representative sample resembling the heterogeneous group of patients seen in clinical practice.

Attrition is a common challenge in prospective FEP studies, including the current 12 , 59 , 78 . Increasing mobility and updated privacy legislation make it more challenging to find and re-recruit participants than in previous decades 79 . The current study has specific problems because the follow-up period was partly overlapping with the COVID pandemic. Some studies have tried to simulate the effect of attrition in longitudinal studies, reporting that associations between variables were not affected even by high attrition rates 80 . However, loss of data from baseline to follow-up is a threat to representativeness and statistical power 80 . We found no differences in demographic or baseline clinical characteristics between completers and non-completers. While baseline data comparisons may address selective loss, the follow-up period is often a black box. Since all participants consented to registry linkage, we could gather comprehensive data on health service utilization for all initial participants. The level of engagement with specialized psychiatric services indicated no differences in illness severities between study completers and non-completers.

Our data shed light on the importance of using established predictors that are validated and underline that there currently are few identified clinical predictors. We identified three long-term outcome groups based on consensus definitions of outcome: CR (28%), TR (31%), and a heterogeneous middle group (40%). We found that the type of onset, baseline disorganized symptoms, premorbid adjustment, and baseline diagnosis were significant predictors of long-term outcomes. These characteristics are readily identifiable in clinical practice and may serve as early identifiers of patients at risk for poor outcomes. We, however, also find that a proportion of patients appear not to be treated according to guidelines constituting a clinical risk for the patients in question.

Supplementary material

Overview of attrition. Tables with group comparison analyses of completers vs. non-completers of 10Y FU. Comparison of national health registry data of completers vs. non-completers (2005 – 2022). Overview of lost-to follow-up due to the Covid-pandemic.

Data availability

Approvals from the Regional Committees for Medical and Health Research Ethics and the Data Protection Officer at Oslo University Hospital based on specific research proposals are required for data sharing, according to Norwegian law. Anonymized data underlying the current analyses are available on request.

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Acknowledgements

We want to thank all our participants for their valuable contributions to the study and our colleagues at NORMENT for their contributions to data collection and administrative tasks. The study was supported by grants from the Research Council of Norway to NORMENT CoE (grant number #223273/F50) and for the present study (grant #287714), in addition to grants from the Southern and Eastern Norway Regional Health Authority (#2006233, #2006258, #2011085, #2014102, #2015088). We also benefited from the TSD p33 resource (#NS9666S). The funding bodies had no role in the analyses or writing of the manuscript or the decision to submit this work for publication.

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K.F.W. and I.M. contributed to the conception, design, and initial drafting of the manuscript. K.F.W., C.F., L.W., G.Å., M.J.E., and S.H.L. contributed to data acquisition. I.V.K. contributed to acquisition and calculation of national health register data. KFW conducted the statistical analyses, while K.F.W., I.M., E.J., and C.S. contributed to the interpretation. All authors read and approved the final manuscript.

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Wold, K.F., Kreis, I.V., Åsbø, G. et al. Long-term clinical recovery and treatment resistance in first-episode psychosis: a 10-year follow-up study. Schizophr 10 , 69 (2024). https://doi.org/10.1038/s41537-024-00489-7

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What is schizophrenia or paranoid schizophrenia?

Early warning signs of schizophrenia, treatment for schizophrenia, diagnosing schizophrenia, schizophrenia symptoms and coping tips.

Recognizing the signs of schizophrenia in yourself or a loved one can be frightening. But with the right treatment and self-help, you can manage the disorder and lead a fulfilling life.

Schizophrenia is a challenging brain disorder that often makes it difficult to distinguish between what is real and unreal, to think clearly, manage emotions, relate to others, and function normally. It affects the way a person behaves, thinks, and sees the world.

The most common form is paranoid schizophrenia, or schizophrenia with paranoia as it’s often called. People with paranoid schizophrenia have an altered perception of reality. They may see or hear things that don’t exist, speak in confusing ways, believe that others are trying to harm them, or feel like they’re being constantly watched. This can cause relationship problems, disrupt normal daily activities like bathing, eating, or running errands, and lead to alcohol and drug abuse in an attempt to self-medicate .

Many people with schizophrenia withdraw from the outside world, act out in confusion and fear, and are at an increased risk of attempting suicide, especially during psychotic episodes, periods of depression, and in the first six months after starting treatment.

While schizophrenia is a chronic disorder, many fears about the disorder are not based in reality. Most people with schizophrenia get better over time, not worse. Treatment options are improving all the time and there are plenty of things you can do to manage the disorder.

Schizophrenia is often episodic, so periods of remission are ideal times to employ self-help strategies to limit the length and frequency of any future episodes. Along with the right support, medication, and therapy, many people with schizophrenia are able to manage their symptoms, function independently, and enjoy full, rewarding lives.

Take any suicidal thoughts or talk very seriously…

If you or someone you care about is suicidal, call the National Suicide Prevention Lifeline in the U.S. at 1-800-273-TALK, visit IASP  or  Suicide.org  to find a helpline in your country, or read  Suicide Prevention .

What is paranoid schizophrenia?

The terms paranoid schizophrenia or schizophrenia with paranoia refer to the most common subtype of schizophrenia, one with pronounced paranoia and delusions. However, paranoid schizophrenia is no longer a recognized diagnosis in the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and the term is rarely used by medical professionals.

Common misconceptions about schizophrenia

Schizophrenia refers to a “split personality” or multiple personalities.

Multiple personality disorder is a different and much less common disorder than schizophrenia. People with schizophrenia do not have split personalities. Rather, they are “split off” from reality.

Schizophrenia is a rare condition.

Schizophrenia is not rare; the lifetime risk of developing schizophrenia is widely accepted to be around 1 in 100.

People with schizophrenia are dangerous.

Although the delusional thoughts and hallucinations of schizophrenia sometimes lead to violent behavior, most people with schizophrenia are neither violent nor a danger to others.

People with schizophrenia can’t be helped.

While long-term treatment may be required, the outlook for schizophrenia is far from hopeless. When treated properly, many people with schizophrenia are able to enjoy fulfilling, productive lives.

In some people, schizophrenia appears suddenly and without warning. But for most, it comes on slowly, with subtle warning signs and a gradual decline in functioning, long before the first severe episode. Often, friends or family members will know early on that something is wrong, without knowing exactly what.

In this early phase of schizophrenia, you may seem eccentric, unmotivated, emotionless, and reclusive to others. You may start to isolate yourself, begin neglecting your appearance, say peculiar things, and show a general indifference to life. You may abandon hobbies and activities, and your performance at work or school can deteriorate.

The most common early warning signs include:

• Depression, social withdrawal.
• Hostility or suspiciousness, extreme reaction to criticism.
• Deterioration of personal hygiene.
• Flat, expressionless gaze.
• Inability to cry or express joy or inappropriate laughter or crying.
• Oversleeping or insomnia; forgetful, unable to concentrate.
• Odd or irrational statements; strange use of words or way of speaking.

While these warning signs can result from a number of problems—not just schizophrenia—they are cause for concern. When out-of-the-ordinary behavior is causing problems in your life or the life of a loved one, seek medical advice. If schizophrenia or another mental problem is the cause, getting treatment early will help.

Speak to a Licensed Therapist

BetterHelp is an online therapy service that matches you to licensed, accredited therapists who can help with depression, anxiety, relationships, and more. Take the assessment and get matched with a therapist in as little as 48 hours.

There are five types of symptoms characteristic of schizophrenia: delusions, hallucinations, disorganized speech, disorganized behavior, and the so-called “negative” symptoms. However, the symptoms of schizophrenia vary dramatically from person to person, both in pattern and severity. Not every person with schizophrenia will have all the symptoms, and the symptoms of schizophrenia may also change over time.

A delusion is a firmly-held idea that a person has despite clear and obvious evidence that it isn’t true. Delusions are extremely common in schizophrenia, occurring in more than 90% of those who have the disorder. Often, these delusions involve illogical or bizarre ideas or fantasies, such as:

Delusions of persecution – Belief that others, often a vague “they,” are out to get you. These harassing delusions often involve bizarre ideas and plots (e.g. “Martians are trying to poison me with radioactive particles delivered through my tap water”).

Delusions of reference – A neutral environmental event is believed to have a special and personal meaning. For example, you might believe a billboard or a person on TV is sending a message meant specifically for you.

Delusions of grandeur – Belief that you are a famous or important figure, such as Jesus Christ or Napoleon. Alternately, delusions of grandeur may involve the belief that you have unusual powers, such as the ability to fly.

Delusions of control – Belief that your thoughts or actions are being controlled by outside, alien forces. Common delusions of control include thought broadcasting (“My private thoughts are being transmitted to others”), thought insertion (“Someone is planting thoughts in my head”), and thought withdrawal (“The CIA is robbing me of my thoughts”).

• Hallucinations

Hallucinations are sounds or other sensations experienced as real when they exist only in your mind. While hallucinations can involve any of the five senses, auditory hallucinations (e.g. hearing voices or some other sound) are most common in schizophrenia. These often occur when you misinterpret your own inner self-talk as coming from an outside source.

Schizophrenic hallucinations are usually meaningful to you as the person experiencing them. Many times, the voices are those of someone you know, and usually they’re critical, vulgar, or abusive. Visual hallucinations are also relatively common, while all hallucinations tend to be worse when you’re alone.

• Disorganized speech

Schizophrenia can cause you to have trouble concentrating and maintaining your train of thought, which may manifest itself in the way that you speak. You may respond to queries with an unrelated answer, start sentences with one topic and end somewhere completely different, speak incoherently, or say illogical things.

Common signs of disorganized speech include:

Loose associations – Rapidly shifting from topic to topic, with no connection between one thought and the next.

Neologisms – Made-up words or phrases that only have meaning to you.

Perseveration – Repetition of words and statements; saying the same thing over and over.

Clang – Meaningless use of rhyming words (“I said the bread and read the shed and fed Ned at the head”).

Disorganized behavior

Schizophrenia disrupts goal-directed activity, impairing your ability to take care of yourself, your work, and interact with others. Disorganized behavior appears as:

• A decline in overall daily functioning
• Unpredictable or inappropriate emotional responses
• Behaviors that appear bizarre and have no purpose
• Lack of inhibition and impulse control

Negative symptoms (absence of normal behaviors)

The so-called “negative” symptoms of schizophrenia refer to the absence of normal behaviors found in healthy individuals, such as:

Lack of emotional expression – Inexpressive face, including a flat voice, lack of eye contact, and blank or restricted facial expressions.

Lack of interest or enthusiasm – Problems with motivation; lack of self-care.

Seeming lack of interest in the world – Apparent unawareness of the environment; social withdrawal.

Speech difficulties and abnormalities – Inability to carry a conversation; short and sometimes disconnected replies to questions; speaking in a monotone.

Daniel’s story

Daniel is 21 years old. Six months ago, he was doing well in college and holding down a part-time job in the stockroom of a local electronics store. But then he began to change, becoming increasingly paranoid and acting out in bizarre ways.

First, he became convinced that his professors were “out to get him” since they didn’t appreciate his confusing, off-topic classroom rants. Then he told his roommate that the other students were “in on the conspiracy.” Soon after, he dropped out of school.

From there, his condition got worse. Daniel stopped bathing, shaving, and washing his clothes. At work, he became convinced that his boss was watching him through surveillance bugs planted in the store’s TV screens. Then he started hearing voices telling him to find the bugs and deactivate them.

Things came to a head when he acted on the voices, smashing several TVs and screaming that he wasn’t going to put up with the “illegal spying” any more. His frightened boss called the police, and Daniel was hospitalized.

As upsetting as a diagnosis of schizophrenia can be, ignoring the problem won’t make it go away. Beginning treatment as soon as possible with an experienced mental health professional is crucial to your recovery. At the same time, it’s important not to buy into the stigma associated with schizophrenia or the myth that you can’t get better. A diagnosis of schizophrenia is not a life-sentence of ever-worsening symptoms and recurring hospitalizations. With the right treatment and self-help , many people with schizophrenia are able to regain normal functioning and even become symptom-free.

Treatment basics

The most effective treatment strategy for schizophrenia involves a combination of medication, therapy, lifestyle changes, and social support.

Schizophrenia requires long-term treatment. Most people with schizophrenia need to continue treatment even when they’re feeling better, in order to prevent new episodes and stay symptom-free. Treatment can change over time, though. As your symptoms improve, your doctor may be able to lower the dosage or change your medication.

Medication for schizophrenia works by reducing psychotic symptoms such as hallucinations, delusions, paranoia, and disordered thinking. But it is not a cure for schizophrenia. It is also much less helpful for treating symptoms such as social withdrawal, lack of motivation, and lack of emotional expressiveness. Finding the right drug and dosage is also a trial and error process. While medication should not be used at the expense of your quality of life, be patient with the process and discuss any concerns with your doctor.

Therapy , either in-person or via an online platform , can help you improve coping and life skills, manage stress , address relationship issues, and improve communication. Group therapy can also connect you to others who are in a similar situation and are able to offer valuable insight into how they’ve overcome challenges.

Medication and therapy can take time to take full effect but there are still ways you can manage symptoms, improve the way you feel, and increase your self-esteem. The more you do to help yourself, the less hopeless and helpless you’ll feel, and the more likely your doctor will be able to reduce your medication.

Schizophrenia: The 7 keys to self-help

Seek social support. Friends and family vital to helping you get the right treatment and keeping your symptoms under control. Regularly connecting with others face-to-face is also the most effective way to calm your nervous system and relieve stress. Stay involved with others by continuing your work or education. If that’s not possible, consider volunteering , joining a schizophrenia support group , or taking a class or joining a club to spend time with people who have common interests. As well as keeping you socially connected, it can help you feel good about yourself.

Manage stress. High levels of stress are believed to trigger schizophrenic episodes by increasing the body’s production of the hormone cortisol. As well as staying socially connected, there are plenty of steps you can take to reduce your stress levels. Try adopting a regular relaxation practice such as  yoga, deep breathing, or meditation .

Get regular exercise. As well as all the  emotional and physical benefits , exercise may help reduce symptoms of schizophrenia, improve your focus and energy, and help you feel calmer. Aim for 30 minutes of activity on most days, or if it’s easier, three 10-minute sessions. Try rhythmic exercise that engages both your arms and legs, such as walking, running, swimming, or dancing.

Get plenty of sleep. When you’re on medication, you most likely need even more sleep than the standard 8 hours. Many people with schizophrenia have trouble with sleep, but getting regular exercise and avoiding caffeine can help.

Avoid alcohol, drugs, and nicotine. Substance abuse complicates schizophrenia treatment and worsens symptoms. Even smoking cigarettes can interfere with the effectiveness of some schizophrenia medications. If you have a substance abuse problem , seek help.

Eat regular, nutritious meals to avoid symptoms exacerbated by changes in blood sugar levels. Omega-3 fatty acids from fatty fish, fish oil, walnuts, and flaxseeds can help improve focus, banish fatigue, and balance your moods.

While the causes of schizophrenia are not fully known, it seems to result from a mix of genetic and environmental factors.

Genetic causes

While schizophrenia runs in families, about 60% of schizophrenics have no family members with the disorder. Furthermore, individuals who are genetically predisposed to schizophrenia don’t always develop the disease, which shows that biology is not destiny.

Environmental causes

Studies suggest that inherited genes make a person vulnerable to schizophrenia. Environmental factors then act on this vulnerability to trigger the disorder.

More and more research points to stress—either during pregnancy or at a later stage of development—as being a major environmental factor. Stress-inducing factors could include:

• Prenatal exposure to a viral infection.
• Low oxygen levels during birth (from prolonged labor or premature birth).
• Exposure to a virus during infancy.
• Early parental loss or separation.
• Physical or sexual abuse in childhood .

Abnormal brain structure

In addition to abnormal brain chemistry, abnormalities in brain structure may also play a role in schizophrenia development. However, it is highly unlikely that schizophrenia is the result of any one problem in any one region of the brain.

A diagnosis of schizophrenia is based on a full psychiatric evaluation, medical history assessment, and physical exam. Lab tests can also help to rule out other medical causes of your symptoms.

Criteria to diagnose schizophrenia

The presence of two or more of the following symptoms for at least 30 days:

• Disorganized or catatonic behavior
• Negative symptoms (emotional flatness, apathy, lack of speech)

Other diagnosis criteria:

• Have had significant problems functioning at work or school, relating to other people, and taking care of yourself.
• Shown continuous signs of schizophrenia for at least six months , with active symptoms (hallucinations, delusions, etc.) for at least one month.
• Have no other mental health disorder, medical issue, or substance abuse problem that is causing the symptoms.

Helplines and support

Call 1-800-950-6264 or visit  NAMI.org

Call 0300 5000 927 or visit  Rethink: Schizophrenia

Call 1800 18 7263 or visit  Sane Australia

Visit  Canadian Mental Health Association for links to helplines and services

Call the Vandrevala Foundation  Helpline  at 1860 2662 345 or 1800 2333 330

More Information

• Schizophrenia - Overview of causes, symptoms, diagnosis, treatment and current research on schizophrenia. (National Institute of Mental Health)
• Schizophrenia: The Journey to Recovery - Handbook discusses diagnosis and treatment issues. (Canadian Psychiatric Association)
• Catatonic Schizophrenia - Symptoms, diagnosis, and treatment. (Cleveland Clinic)
• Disorganized Schizophrenia - Signs and symptoms of this subtype. (PsychCentral)
• Schizophrenia Spectrum and Other Psychotic Disorders. (2013). In Diagnostic and Statistical Manual of Mental Disorders . American Psychiatric Association. Link
• Patel, Krishna R., Jessica Cherian, Kunj Gohil, and Dylan Atkinson. “Schizophrenia: Overview and Treatment Options.” Pharmacy and Therapeutics 39, no. 9 (September 2014): 638–45. Link
• Ganguly, Pronab, Abdrabo Soliman, and Ahmed A. Moustafa. “Holistic Management of Schizophrenia Symptoms Using Pharmacological and Non-Pharmacological Treatment.” Frontiers in Public Health 6 (2018): 166. Link
• Aquino, Patrick. “Diagnosing and Treating Schizophrenia.” AMA Journal of Ethics 11, no. 1 (January 1, 2009): 43–48. Link
• Gage, S. H., H. J. Jones, S. Burgess, J. Bowden, G. Davey Smith, S. Zammit, and M. R. Munafò. “Assessing Causality in Associations between Cannabis Use and Schizophrenia Risk: A Two-Sample Mendelian Randomization Study.” Psychological Medicine 47, no. 5 (April 2017): 971–80. Link
• Chien, Wai Tong, Sau Fong Leung, Frederick KK Yeung, and Wai Kit Wong. “Current Approaches to Treatments for Schizophrenia Spectrum Disorders, Part II: Psychosocial Interventions and Patient-Focused Perspectives in Psychiatric Care.” Neuropsychiatric Disease and Treatment 9 (2013): 1463–81. Link
• Stępnicki, Piotr, Magda Kondej, and Agnieszka A. Kaczor. “Current Concepts and Treatments of Schizophrenia.” Molecules: A Journal of Synthetic Chemistry and Natural Product Chemistry 23, no. 8 (August 20, 2018): 2087. Link
• Catts, Stanley Victor, and Brian Ignatius O’Toole. “The Treatment of Schizophrenia: Can We Raise the Standard of Care?” Australian & New Zealand Journal of Psychiatry 50, no. 12 (December 1, 2016): 1128–38. Link
• Knight, Edward L. “Self-Help and Serious Mental Illness.” Medscape General Medicine 8, no. 1 (March 15, 2006): 68. Link
• “Self-Management: The Experiences and Views of Self-Management of People with a Diagnosis of Schizophrenia – Social Care Online.” Accessed November 2, 2021. Link
• Sensky, T., D. Turkington, D. Kingdon, J. L. Scott, J. Scott, R. Siddle, M. O’Carroll, and T. R. Barnes. “A Randomized Controlled Trial of Cognitive-Behavioral Therapy for Persistent Symptoms in Schizophrenia Resistant to Medication.” Archives of General Psychiatry 57, no. 2 (February 2000): 165–72. Link
• Pilling, S., P. Bebbington, E. Kuipers, P. Garety, J. Geddes, G. Orbach, and C. Morgan. “Psychological Treatments in Schizophrenia: I. Meta-Analysis of Family Intervention and Cognitive Behaviour Therapy.” Psychological Medicine 32, no. 5 (July 2002): 763–82. Link
• Turkington, Douglas, David Kingdon, and Peter J. Weiden. “Cognitive Behavior Therapy for Schizophrenia.” The American Journal of Psychiatry 163, no. 3 (March 2006): 365–73. Link

More in Schizophrenia

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Proven ways to help your loved one accept the treatment they need

Electroconvulsive Therapy (ECT)

How it works and how to decide if it’s the right treatment for you

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How to help someone who is suicidal and save a life

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August 27, 2024

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Ohio study reveals high risk of overdose deaths among those using drugs when they're alone

by Case Western Reserve University

In Cuyahoga County, the stark reality of the opioid crisis is that most drug overdose victims die alone, with no one nearby to help. A recent study , done in partnership with Case Western Reserve University and Cuyahoga County, highlights the critical need for "targeted harm-reduction strategies" in Northeast Ohio, where the opioid epidemic continues to claim lives at nearly twice the national average. The paper is published in the journal Substance Use & Misuse .

Those strategies include the distribution of Naloxone (an opioid antagonist that can reverse the effects of an overdose ), and increasing the availability of medication-assisted treatment options and fentanyl test strips.

The research, using data from the Cuyahoga County Medical Examiner's Office, examined overdose deaths between 2016 and 2020, focusing on people using drugs when they were alone.

The study revealed that a staggering 75% of overdose victims were using drugs alone, a behavior strongly associated with increased mortality. Key findings indicate that individuals using drugs alone were more likely to be at home and less likely to receive life-saving interventions like naloxone, said Daniel Flannery, the Dr. Semi J. and Ruth Begun Professor and director of the Begun Center for Violence Prevention Research and Education at CWRU's Jack, Joseph and Morton Mandel School of Applied Social Sciences.

"Being informed is crucial—knowledge equips you to take action," Flannery said. "It's about reviving someone in need, and if that's not possible, contacting emergency services immediately. The chances of a fatal outcome significantly increase when there's no one around to help."

New policies and community efforts must prioritize reaching individuals at risk of using alone to curb the devastating impact of the opioid crisis, said Vaishali Deo, research associate at the Begun Center and co-principal investigator in the research.

"Our findings underscore the urgent need for innovative harm-reduction strategies aimed at those most vulnerable—those using drugs alone," Deo said. "Interventions must focus on reducing isolation and improving access to emergency medical care to prevent further loss of life."

Additional insights include:

• In Cuyahoga County, from 2016 through 2020, there were 2,944 unintentional overdose deaths for those over 18 years old. That's 54 deaths per 100,000 residents. The national average is 28 overdose deaths per 100,000 residents.
• The study further details the demographics and circumstances surrounding overdose deaths in Cuyahoga County from 2016 to 2020. Most were non-Hispanic (94.9%), white (72.2%) and male (71.3%), with a significant portion 35 to 64 years old. Most lived in the City of Cleveland. Over half attained at least a high school diploma.
• Toxicology reports revealed that synthetic opioids, specifically illicitly manufactured fentanyl, was present in 72.7% of the deaths. Cocaine and heroin were also significant contributors, found in 41.6% and 29.6% of cases, respectively. Nearly 80% of overdose deaths involved the use of multiple substances.
• Despite the presence of bystanders in more than half the cases, most victims (74.9%) were using drugs alone at the time of their fatal overdose, mainly at home. Emergency medical services responded to most of the incidents, yet over 60% of victims were pronounced dead at the scene—highlighting the critical timing needed for interventions like naloxone, which was administered in just 28.6% of the cases.

Deo and Flannery were joined in the research by Sarah Fulton, a research associate at the Begun Center, and Manreet K. Bhullar, a senior forensic epidemiologist at the Cuyahoga County Medical Examiner's Office, and Thomas P. Gilson, chief medical examiner of Cuyahoga County.

"These findings paint a stark picture of the opioid crisis in our community," Gilson said. "The tragic reality is that too many people are dying alone, and we must act swiftly to implement lifesaving measures that can prevent these unnecessary deaths."

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