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GPs have a central role in managing schizophrenia

How should schizophrenia be diagnosed?
How should patients be monitored?
What are the treatment options?

How should schizophrenia be diagnosed?
How should patients be monitored?
What are the treatment options?

Schizophrenia is a major psychiatric disorder affecting approximately 1 in 100 people during their lifetime. Although the prognosis is highly variable, the condition tends to run a chronic course and is associated with considerable morbidity and mortality. The substantial disability associated with schizophrenia has been estimated to account for 1.5-3% of healthcare expenditure in the UK.1

In recent decades the care of people with schizophrenia has shifted from hospital to the community. The GP's role has thus expanded, a fact reflected by the emphasis placed on primary care involvement in the recently updated NICE guideline on schizophrenia.2 On average GPs in the UK will have 7-12 people with schizophrenia on their lists, and for some of these patients they may be the sole provider of care.3, 4 This, together with the central role of the GP in initial diagnosis of the condition, underlines the importance of GPs keeping abreast of developments in research and treatment of schizophrenia.

Risk factors

Schizophrenia affects both sexes, all races and every socioeconomic class. It typically presents in late adolescence or early adulthood, the age of onset is a few years later in women than men. The aetiology is explained by the ‘vulnerability-stress' model, the condition manifests as a result of interactions between biopsychosocial predisposition and environmental stress.5 In keeping with this model, certain groups are known to be at particular risk of developing the condition:
• People who have a first-degree relative with schizophrenia
• Certain ethnic groups
• Adolescents and young adults – (the vast majority of first episodes of psychosis occur between the ages of 16 and 30)
• People with a vulnerable personality – (e.g. eccentricities of behaviour, cognitive and /or perceptual distortions, poor social adjustment)
• Drug users

Detection

In the majority of cases, schizophrenia develops insidiously, sometimes over several years. This period is characterised by subtle symptoms and social decline (see table 1, attached). When concerns are raised it is generally by friends or family.

Increasing recognition of the importance of prompt initiation of treatment for schizophrenia has resulted in considerable focus on early detection.6 Achieving this is contingent upon GPs having a high index of suspicion. It is hoped that early detection and treatment will impact on the prognosis of the condition. However, there are several stumbling blocks. Prodromal symptoms are vague, the provision of early intervention services is patchy and even without treatment only approximately 30% of individuals identified will go on to develop schizophrenia.

The GP is ideally placed to respond to family concerns, identify prodromal symptoms, screen for psychotic symptoms (see table 2, attached) and initiate either a mental health review or active monitoring in primary care. Given that suspiciousness is a central feature of psychosis, the patient may be reluctant to attend the practice; while keeping personal safety paramount, if the history is suggestive of psychosis every effort should be made to assess the person. If the patient is deteriorating, psychotic symptoms are present or there are doubts about management, referral to the mental health team is indicated.

Diagnosis

Diagnosis is based on symptomatology (see table 3, attached) and should be made by a psychiatrist. It centres on the clarification of psychopathology and investigations to exclude an organic cause (see table 4, attached).

The GP plays a central role in:
• providing a basic assessment
• evaluating risk
• identifying the most appropriate mental health resource
• initiating or arranging emergency admission for treatment. If clinical circumstances dictate, on occasion GPs may be requried to utilise the emergency provisions of the Mental Health Act.

There are a range of different mental health services and the structure varies from region to region (see table 5, attached), but all will have resources in place for psychiatric emergencies. If the risk to self or others is considered significant, then urgent referral to the mental health service is mandatory. This will generally involve direct discussion with the clinicians involved.treatment

Antipsychotic medication is the cornerstone of treatment. Although the original NICE guideline recommended the use of second generation antipsychotics (‘atypicals') as first-line treatment, this is not the case in the revised guideline. This change reflects acknowledgement of the fact that: all antipsychotics (with the probable exception of clozapine) are of similar efficacy, and although second-generation antipsychotics have a lower propensity to cause extrapyramidal side-effects (EPSEs) at therapeutic doses, some (especially clozapine and olanzapine) have a greater propensity to cause the metabolic syndrome.

The importance of involving patients in choosing appropriate antipsychotic treatment is emphasised, and it is important to discuss the relative benefits and side-effects of the different preparations. Depot preparations can be invaluable when compliance is an issue, although their administration in patients refusing treatment will necessitate use of the Mental Health Act.

Antipsychotic medication will generally be started by, or following discussion with, a psychiatrist. If immediate initiation is felt to be necessary and this discussion is not possible, the chosen drug should be commenced at the lower end of the therapeutic range e.g. risperidone 1mg, increasing to 2mg following review. The introduction of antipsychotics is a therapeutic trial, and as such response to treatment and side-effects should be carefully documented.

Following their first episode of psychosis 15-20% of patients will have no further episodes, 5-10% will have a largely treatment-resistant psychosis and the rest will have significant recovery but further episodes. To minimise the chance of relapse antipsychotics are continued for a minimum of 1-2 years and discontinued gradually. A second episode will generally necessitate prolonged and possibly lifelong treatment.

Monitoring

The wide range of potential adverse consequences of antipsychotic treatment necessitates active monitoring (see table 6, attached).

Practitioners should be particularly alert to extrapyramidal side-effects (EPSEs) such as parkinsonism and akathisia. The former (best detected by observing gait or eliciting the presence of cogwheel rigidity) responds to dose reduction, a change to a second generation preparation or addition of an anticholinergic such as procyclidine. The latter (a feeling of inner restlessness associated with an irresistible urge to move the legs) may be helped by addition of a benzodiazepine. However, the highly unpleasant nature of akathisia and strong association with suicide necessitates discussion with a psychiatrist. In patients on long-term treatment it is important to be vigilant for evidence of tardive dyskinesia (repetitive, purposeless movements of the muscles of the face and tongue); once established it can persist even on discontinuation of antipsychotics.

The NICE guideline places particular emphasis on psychosocial interventions. The updated guideline recommends that all patients with schizophrenia should be offered cognitive behaviour therapy (CBT) for persistent positive symptoms and to prevent relapse, and family therapy (FT) to help families cope more effectively with the patient's problems and prevent relapse. It also suggests that arts therapy should be considered for negative symptoms.

While these interventions are certainly desirable, the reality is that implementation is hampered by resource limitations; despite CBT and FT being recommended in the original NICE guideline, only half of eligible patients were offered these interventions.

A major cause of early mortality in schizophrenia is suicide; 10% of patients kill themselves. Suicide is more likely to occur in the first few years following diagnosis, and it is important to be vigilant for depressive symptoms. The usual predictors of suicide (male, isolated, unemployed etc) contribute to risk, but particular vigilance is necessary with the educated, insightful young man painfully aware that his ambitions are unlikely to be fulfilled. Substance misuse is also a major concern, increasing suicide risk, compounding social decline, and precipitating relapse. It should be actively screened for and particularly suspected in cases of poor treatment response.

Key roles of the primary care team

Many patients with schizophrenia will receive considerable input from secondary care services. The GP still has a central role to play in the care of these patients however, which will encompass many spheres:

• Identification of initial episode of psychosis
• Attending to patient and family distress arising from diagnosis and providing information about the condition
• Building a relationship with family/carers and contributing to work on relapse prevention/recognition of relapse signature
• Providing continuity of care and ensuring good communication between services. This may be particularly important with the profusion of specialised mental health teams
• Attending to/monitoring physical health needs
• Health promotion/smoking cessation
• Monitoring mental health and instituting secondary care review when indicated
• Identification of drug and alcohol problems
• Vigilance for social problems, child protection concerns etc
• Severe mental illness registers have been proposed as a means of ensuring that a structured approach is used in providing this care and encouraging contact with primary care services.

In many areas the interface between primary and secondary care has been formalised through the development of shared care protocols, though the focus of these is often limited to medication prescribing.

One of the most fundamental roles of the primary care team is the provision of adequate physical health care. Patients with schizophrenia frequently have manifold risk factors for physical ill health, including:
• smoking
• excessive alcohol use
• drug misuse
• poor nutrition and hygiene
• obesity
• sedentary lifestyle
• poverty

When the weight gain, impaired glucose tolerance and dyslipidaemia associated with antipsychotic treatment (especially second generation preparations) is added in to this mix, it is all too understandable that the death rate from cardiovascular disease in this population is roughly doubled. 7

Despite this acknowledged excess morbidity and mortality however, it has been reported that people with schizophrenia are half as likely as asthma patients to have risk factors such as blood pressure and cholesterol recorded.8 Recognition of this unmet need has led to an increased focus on the importance of monitoring risk factors for physical morbidity, primary and secondary prevention, and encouragement of the use of general practice case registers to ensure these needs are addressed.2 The QOF indicators for mental health are shown in table 7, attached. Physical health monitoring should be undertaken at least annually.

The GP is also central to providing continuity of care, being alert to carer needs, flagging up any child protection concerns and helping families negotiate the frequently byzantine variety of mental health resources.

Additionally, having often been the only professional to have known the patient before they became unwell, the GP has the invaluable ability to place a psychotic episode within the context of what is ‘normal' for that person. This knowledge will be particularly important when an application for use of the Mental Health Act is being made, and underlines the importance of the GP's report in these circumstances.

MRI neuroimaging scans of the brain in patients with schizophrenia compared with normal controls Figure 1 Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Key points Further reading

For a discussion of the empirical status of early intervention services, see: Cannon T D, Cornblatt B, and McGorry P. Editor's introduction: The empirical status of the ultra high-risk (prodromal) research paradigm. Schizophr Bull 2007: 33; 661

Author

Author
Dr Killian Welch
MB ChB MPhil MRCPsych
clinical lecturer in general adult psychiatry, University of Edinburgh

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