Schizophrenia in Young Women and Men

Schizophrenia is a heterogeneous disorder and can be characterized by any of the following symptoms: intellectual deterioration, emotional blunting, disorganized speech, disorganized behavior, social isolation, delusions, and/or hallucinations (American Psychiatric Association [APA], 2000). In the current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) schizophrenia has now been divided into five subcategories (APA, 2000). These subtypes are defined based on the presence of positive symptoms (excesses, such as hallucinations and delusions) or negative symptoms (deficits, such as social isolation and poverty of speech) of behavior in the presentation of the disorder.

There is no defined cause for schizophrenia although many have been proposed. First, it is generally acknowledged that schizophrenia is at least in part caused by an imbalance of neurotransmitters. The classical "dopamine hypothesis" of schizophrenia has asserted that there is a hyperactivity in dopaminergic transmission at the dopamine D2 receptor in the projections to the limbic system in the brain (Matthysse, 1974). Despite several limitations this hypothesis still remains the most popular of the neurochemical theories. The other line of evidence is heredity, suggesting genes play a role in schizophrenia. However, it is still unclear if schizophrenia is the result of a single mutated gene, a series of mutated genes, or a mutated gene passed from parents. The concordance rate between monozygotic twins for schizophrenia is around .5 in most studies (Cohen, 2003; Sadock & Sadock, 2007).

Psychotherapy for schizophrenia has rarely been considered a first line treatment and the first line treatments for schizophrenia today consist of medications. Older drugs such as and Haldol primarily work as dopamine antagonists, whereas new atypical antipsychotics such as risperadal and clozipine affect dopamine and serotonin. Of course problems with medications have been compliance and side effect profiles (APA. 2000). Older drugs are associated with side effects such as tardive dyskinesia (uncontrollable movements), whereas the atypical antipsychotic drugs have fewer side effects (but each drug still has a side effect profile). The side-effects of the medications often lead to their discontinuation by the patient. All medications for schizophrenia take several weeks before they take effect (another problem for the dopamine hypothesis as dopamine is blocked soon after the drug is taken) and up to 20% of patients will not respond to medication at all (Hyman & Fenton, 2003). The pharmacological treatments for psychotic illnesses have grown exponentially in the past quarter of a century using antipsychotic medications and mood stabilizers, which has led to a limited focus in the current psychiatric textbooks only describing the medications available and helping patients understand the limitations of what can be offered (Cohen, 2003; Sadock & Sadock, 2007).

The problem with the medical model of treatment for schizophrenia

Despite the use of medications, there are some pitfalls to the medical model. First, in the pre-neuroleptic period before these drugs were developed and before there were long-term follow-up studies approximately two-thirds of schizophrenic patients made good social recoveries (Bleuler 1968; Ciompi 1980). Based on a large meta-analysis of patients covering nearly a 100 years from 1895 to 1992 it also appears that outcome for persons with a diagnosis of schizophrenia is worse now than it was before treatment with neuroleptics medications dominated the field (Hegarty, et al., 1994). The World Health Organization's (WHO) findings from a nine-country study of schizophrenia indicated that at the five-year follow-up period nearly 63% of patients from third world developing countries were doing well compared to 39% of those from developed countries. The most parsimonious explanation that could be offered for this surprising finding is that only 16% of third world country patients were maintained on neuroleptics medications compared with 59% from developed countries (Whitaker, 2002). Moreover, patients on long-term medication therapy have significantly shorter life expectancies and a higher rate of other chronic health issues. In a similar vein there is an emergent body of research that indicates that many of the standard treatments in psychiatry (e.g., medications) are no more effective than active placebos (e.g., see Kirsch, 2010). Thus, the perhaps viewing schizophrenia as a brain disease is missing something. Moreover numerous studies that have demonstrated psychotherapy and understanding care is more effective for schizophrenia than medications have been ignored by modern psychiatry (Whitaker, 2002).

There have been successful non-medication approaches to treating schizophrenia in the past. For example the most famous of these is Diabasis, an experimental residential facility in San Francisco, CA in the 1970s founded by John Weir Perry, a Jungian trained psychiatrist who advocated not using medications to treat schizophrenics. The facility contained schizophrenic patients who were treated with a combination of psychotherapy that was based on Jungian principles and Weir's additions to Jungian theory. Medication use was not allowed (Perry, 1974; 1999). The residence consisted of typical living facilities and the addition of a "venting room" used to let the residents express their personal concerns, regardless of the issue, their nature, or of their intensity. Perry believed that professional mental health care workers had stereotyped conceptualizations of schizophrenic patients that would interfere with the type of treatment that these patients actually required so he used non-professional health care workers to work with the clients in his facility. Perry (1999) later reported that the qualifications he sought for the workers included being open to different experiences, being gregarious, and able to be a good listener. The staff's duties consisted of mostly of caretaking, some therapy (primarily listening and empathizing) and other chores. The complete details of the program can be found in Perry (1999). The general treatment protocol at Diabasis consisted of meditation, painting, massage, dance, and forms of talk therapy. In 1999 Perry published some of the data on his program, which unfortunately had closed after just a few years of operation because of budget cutbacks. According to the data the average length of stay for a client was only 48 days. Perry reported that even the most severely psychotic patients were coherent within two to six days. In his report Perry claimed to have an 85% success rate without remissions. He also noted better outcomes for those clients with fewer than three previous psychotic outbreaks.

There are other studies that indicate that newly identified schizophrenic patients who are treated with specialized psycho-social methods and few or no neuroleptic drugs, recover as well as drug-treated patients in the short run (e.g., Mosher and Menn, 1978; 1979). At two-year follow-ups of patients treated in programs without drugs indicates that these patients have better outcomes than patients in similar programs who receive neuroleptics medications (Bola and Mosher, 2003). Therefore, consistent with Perry (1999) it appears justified to expect recovery for most persons with early-episode psychosis if the proper conditions can be maintained to foster their recovery.

Rationale for the research and hypothesis

However, there have been no randomized controlled trials comparing residential treatment outlined by Perry and Mosher and associates (Soteria project) to standard pharmacotherapy for schizophrenia. The reason for this is that psychiatry has eschewed its back on any treatment for schizophrenia that does not consist of medications. Using a true control group for patients with a severe disorder like schizophrenia brings up ethical concerns as well. However, it would be acceptable to use random assignment to two treatment conditions, one medication and one residential to test the issue. Such a study comparing the effects of residential treatment vs. standard treatment with a long-term follow-up would answer many questions regarding the effectiveness of nonstandard residential treatments that apply the principles of Perry and Mosher vs. medication. Based on previous findings it is proposed that residential treatment for newly diagnosed people with schizophrenia will demonstrate equivalent efficacy to the standard medical treatments at the end of the treatment period; however, over a two-year follow-up period patients in the residential treatment program will demonstrate fewer relapses and better social and occupational functioning.

Methods

Participants

Thirty first time diagnosed participants with schizophrenia will be randomly assigned to residential treatment or standard treatment with medications. The participants will not have any other psychiatric diagnoses, have never been on psychiatric medications, no history of substance abuse, and no serious medical disorders.

There will be 15 patients in each condition and there will be an effort to match patient pairs on demographic variables such as gender, age, education, etc. And the type and severity of their disorder and then randomly assign each to one of the two treatment conditions. The diagnosis of schizophrenia will be made by a licensed psychiatrist in the context of a community mental health center, hospital, or other psychiatric facility. Medications in the medication group will be prescribed by a psychiatrist.

Materials and Resources

Facility needs:

Residential facility with 6 rooms for patients, group room, kitchen, dining room, two bathrooms, staff headquarters, furniture, appliances. Food, hygiene supplies, toiletries to be replenished weekly.

Assessment and statistical analysis materials:

Only standardized instruments that have been previously used for the assessment of symptoms and social functioning in schizophrenia will be used for the study. The following are three instruments will be used:

The Brief Psychiatric Rating Scale (BPRS; Overall & Gorham, 1962) is a rating scale used to measure psychiatric symptoms for research or clinical purposes. The symptoms are rated on 24 items and include depression, anxiety, hallucinations and unusual behaviors. Each symptom is rated 1-7 scale Likert type scale. It is the most used symptom scale in psychiatry and has demonstrated excellent reliability and validity.

The Social Functioning Scale (SFS; Birchwood et al., 1990) can be used as a self-report measure or be completed by an informant. It has 79 items and measures social functioning across multiple domains. The questions are answered in an interview format.

The Social Behavior Schedule (SBS; Wykes & Sturt, 1986) takes 15 minutes to be rated by a researcher or clinician, assessing the previous month's functioning. It assesses 21 areas of functioning that can be grouped in four areas of behavior and has demonstrated excellent reliability and validity.

Lab top computer; SPSS statistical program software.

Staffing

Supervising psychiatrist, two psychologists, and psychiatric nurse. Ten advanced clinical psychology graduate students or social work students.

A proposed budget for the materials and personal is presented in Appendix A.

Measures

The independent variables are the form of treatment. The dependent variables are the scores on the BPRS, SFS, SBS, number of relapses during the follow-up period, and review of the medical records for the patient. There will also be the potential to analyze group differences on the subscale scores of these measures and to look at group differences on item scores. Record review will be concerned with relapse which is defined as any record indicating a return of the schizophrenic symptoms or any psychiatric hospitalization.

Design

The design is essentially has a two level independent variable (treatment group) and four dependent measures that are measured over multiple time points (time can also be treated as a dependent measure). The study uses a quantitative design. Multivariate statistics will be used for their power. The use of SPSS procedures descriptive statistics, measures of reliability for the outcome measures (alpha), correlations, T-tests, MANOVA (with appropriate post hoc tests), ANOVA (with appropriate post hoc tests), multiple regression, and logistic regression will be used to analyze the data over multiple assessments. Trends and time series can also be considered. Alpha level will be set at .05 for the analyses.

Procedure

Participant recruitment

Following IRB approval persons with schizophrenia will recruited for the study from participating psychiatric facilities. Informed consent will be collected from the participant or in the case of participants with legal guardians from the guardian. All participants will have first episode schizophrenic diagnoses and exclusion criteria are listed in the participants section. The inclusion criteria ensure equivalence between the two treatment conditions. Participant recruiting will continue on an ongoing basis until the cells in the design are filled. Random assignment will be attempted, but certainly after a certain point in the recruitment processes it is possible that certain participants will be intentionally assigned to a condition to ensure a balanced design regarding the demographic characteristics of the groups.

Treatment groups and assessments

Participants in the medication treatment group will be followed by their treating psychiatrists. These patients should not receive any adjunctive psychotherapy, but this may not be practical. If they do receive adjunctive psychotherapy it will be noted. Participants will be assessed by research assistants on the three standardized measures at baseline, and at two, four, six, ten, and 12 weeks (the proposed length of the residential program). Participants will also be assessed at follow-up at six months, one year, 18 months, and two years.

Participants in the residential treatment will follow the same assessment procedure as those in the medication group. Residential treatment will consist of the procedures outlined by Mosher and associates used at the Soteria program (Mosher & Menn, 1977;1978) and Perry (1999) which allows for patients to vent, uses non-medical staffing, maintaining the patient's personal power, using social networks, and helping patients find meaning in the subjective experience of psychosis. Ten clinical psychology graduate students will be recruited from graduate programs in psychology and local graduate schools and trained in these methods by two supervising psychologists. Internship opportunities may be possible and it is also acceptable to recruit research assistants from social work programs. Research assistants will be assigned shift duties (two each in two day shifts). Midnight shifts will be covered by non-clinical paid staff who will be trained in crises management. No therapy will occur when the patients are sleeping. A supervising psychologist will be on the grounds during the day. The treatment programs will be standardized and manualized in line with the Diabasis and Soteria programs. Research assistants in the residential condition will be required to complete daily shift notes on each participant.

Proposed time frame

There will be a maximum of five participants in the residential treatment condition at a time. The residential treatment is designed to last 10 weeks. So the expected length of the residential treatment center is about 30 weeks, but recruiting complications may extend this to 50 weeks. The research program is expected to run the full 50 weeks.

Additional staff

In addition to psychological staff the residential program will have an on-call psychiatrist and psychiatric nurse that will be available for consultation in the event of emergencies. Although the residential treatment program is considered to be medication-free the potential for some patients to need minimal medication treatment is very real, and this is consistent with the Soteria program (Mosher & Menn, 1978). In the event that medications are needed for some residential treatment participants this information will be documented and could potentially be compared to medication treatment participants with regards to dosage needed, time on medications, etc. The supervising psychiatrist can also remove a residential participant from the program if it is deemed that this is in the best interest of the patient.

Assessments will be performed by volunteer research assistants that are not involved in the treatment of the participants, are blind as to the aim of the study, and are assigned to assess only one condition (e.g., the participants in either the medication or residential group). This will partially control for experimenter bias. Assessment research assistants will be fully trained in the use of the standardized measures and in how to read the progress charts by the supervising psychologists. Assessment research assistants will also be trained to enter data into the SPSS program for later analysis. Research assistants will check the data of their counterpart for errors. In order to maintain confidentiality each study participant will be assigned a number for identification.

Discussion

This study will test the effects of residential and essentially non-medication treatment on schizophrenia. There is sufficient research to question the effectiveness of antipsychotic medications in the management of schizophrenia, the long-term prognoses for patients on these medications, and the effectiveness of residential treatment (e.g., Hegarty et al., 1994). Such medication use also results in significant risk for health complications and mortality in these patients. In addition, past studies investigating a Jungian approach to the treatment of psychosis demonstrated promise (e.g., Perry, 1999), but ran out of funding in the 1980s when the development of many psychiatric medications began to dominate the treatment of psychotic disorders. The application of the Jungian notion of psychosis is best exemplified by the practices of the late psychiatrist, John W. Perry.