5.1.4 treatments for sz Flashcards Preview

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biological treatment : anti-psychotic drug treatment - what is it

if schizophrenia is caused by an excess or deficiency of a certain neurochemical, the medication can be used to correct this imbalance

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biological treatment : typical or first generation anti psychotics (FGA’s)

chlorpromazine was the first antipsychotic medication, discovered in the 1950s as a tranquilizer.

It is a dopamine antagonist, which greatly reduces positive symptoms by blocking postsynaptic dopamine receptors, without activating them.

The most effective FGA is all those that bind to D2 receptors. These are one of the main receptors implicated in schizophrenia.

Although first-generation antipsychotics are effective in reducing positive symptoms for many people, as many as 40% gain no relief at all and many people still experience negative symptoms (barlow and durand 1995)

they are also known to have some unpleasant side-effects such as traduce dyskinesia which can lead to support compliancy and subsequent relapses - hartling et al 2012 Found evidence of a higher risk of dyskinesia for chlorpromazine was 9% and four clozapine was 5%

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biological treatment : atypical or second generation antipsychotics (SGAs)

clozapine was developed in the 1960s and blocks dope mean in the same way as first-generation antipsychotics but additionally acts on serotonin and glutamate receptors, e.g. blocking serotonin receptors. This reduces both positive and negative symptoms.

rispendone Is a more recently developed SGA. It is also believed to buy into serotonin as well as dopamine and it binds more strongly to dopamine receptors than clozapine so as affective in much smaller doses the most antipsychotics

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biological treatment : EVALUATE DRUG TREATMENTS FGAS in particular

FGAs = hartling et al said that their conclusions cannot be that firm because all studies had some risk of bias and the follow-up was often too brief to measure adverse effects over time. He also said that the studies tended to use selective populations so generalisability was also limited. Therefore hartlingcould not conclude with regard to 1st and second generation antipsychotic drug that one was better than the other

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biological treatment : EVALUATE DRUG TREATMENTS SGAs in particular

One side effect is the potentially fatal blood condition which has led to this drug (clozapine) falling out of favour though it is still use within treatment resistant clients. It provides relief for up to 60% of such people (lally and macCabe 2015). clients have regular blood tests to avoid blood conditions

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evaluating drug treatments in general

Large meta-analysis
A strength of drug treatments for schizophrenia is good empirical evidence. For example, Ving Jiao Zhao et al. (2016) conducted a meta-analysis comparing 18 antipsychotics and utilising data from 56 randomised control trials (RCT) with over 10,000people. They found that 17 of the
antipsychotics tested had significantly lower relapse rates than the placebos.
This shows that drug treatments can be helpful, allowing people with schizophrenia to avoid the emotional and financial costs of hospital treatments which may be the only alternative if medication fails.

Competing argument Krishna Patel et al. note that 20% of people with schizophrenia show negligible improvement after multiple GA trials and around 45% experience only partial orinadequate improvement and unacceptable side effects. Furthermore,
While reduced relapse is important, the reality is that many people with schizophrenia who are taking drugs actually fail to function well in everyday life and the vast majority are unemployed.

Data drawn from research with animals
A weakness is that much research on drug treatments of schizophrenia is conducted on animals. Shitij Kapur et al. (2000) caution against overgeneralising from animal studies. High doses of medication can be given to animals so that D2 receptors can be effectively blocked (but doing this would lead to severe side effects in humans). Such research may demonstrate that
symptoms are reduced but animal models cannot show how such side effects would interfere with everyday life or whether this would lead to lack of compliance. This shows that laboratory research cannot always replicate the lived experience of taking daily medication and coping with incapacitating side effects, which can be a major barrier to treatment.

Biased evidence
A further weakness of evidence supporting drug treatments is that it may be selectively reported. Erick Turner et al. (2012) claim that there is evidence of a publication bias towards studies
that show a positive outcome of antipsychotic drugs (though it is less of a problem than for antidepressants). The consequence is that the effectiveness of such drugs is exaggerated. Drug
companies have a strong interest in the continuing success of psychotherapeutic drugs and much of the research is
these companies. This could lead doctors to make inappropriate treatment decisions that may not be in the best intention of their clients.

Application to de-institutionalisation
In previous decades people with schizophrenia would have had little choice but to spend their lives in institutional care. the advent of antipsychotic drugs in the 1950s meant an enormous change in the way people with schizophrenia could live their lives. Once a person was placed in a mental hospital they became institutionalised and unable to cope on their own. Antipsychotic drugs meant that people with a diagnosis of schizophrenia had the chance to remain in the community
this is important because the segregation of people with mental health problems into long- stay hospitals further increases stigmatisation through lack of contact with the rest of the community.

ADDITIONAL CONSIDERATIONS
Amphetamines, alcohol, caffeine and nicotine can all disrupt the effectiveness of antipsychotic medications.

Therefore support for substance use may also be a consideration when treating a person Venter psychotics.

Drug treatments often fail to bring relief to people who experience symptoms for many years as it appears that the first five years following an acute episode can lead to the most significant changes in the brain Patel 2014

Since the mid-1950s antipsychotic medications have greatly improved treatment. Medications reduce positive symptoms particularly hallucinations and delusions; and usually allow the patient to function more effectively and appropriately.

Antipsychotic drugs are highly effective as they are relatively cheap to produce,
easy to administer and have a positive effect on many sufferers. However they do not "cure" schizophrenia, rather they dampen symptoms down so that patients can live fairly normal lives in the community.

Kahn et al. (2008) found that antipsychotics are generally effective for at least one year, but second- generation drugs were no more effective than first-generation ones

ethical issues : social control. Antipsychotics have been used in hospitals to calm patients and make them easier for staff to work with rather than for the patient’s benefit which can lead to the abuse of the human rights act

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Cognitive behaviour treatment ao1

COGNITIVE-BEHAVIOURAL TREATMENT
Cognitive-behavioural treatment (CT) is a form of therapy that combines a cognitive approach (the way a person thinks) with learning theory concepts which aim to change behaviour (such as reinforcement). It is now commonly used to treat clients with schizophrenia, It usually takes place in anywhere between five and 20 sessions, either in groups or individually.

Irrational thoughts
The aim of CBT in general involves helping clients identify irrational thoughts and try to change them. People with schizophrenia often lack necessary coping skills to manage their symptoms leaving them vulnerable to stress, which can trigger relapse. Reducing the stress of the situation, by altering the way the person thinks and feels can help to prevent decompensation (a decline from normal functioning into a psychotic episode). The therapist will build self-awareness by helping the individual to understand more about their condition. This should help them to recognise specific situations which precede
decompensation, allowing them to initiate coping strategies, such as stress management techniques (egmeditation).

Delusions
People with schizophrenia typically experience delusions and hallucinations, both related to irrational thinking. They can be helped to make sense of how their delusions and hallucinations impact on their feelings and behaviour. Just understanding where symptoms come from can be hugely helpful for some clients. If, for example, a client hears voices and
believes the voices are demons, they will naturally be very afraid. Offering non-biological explanations for the existence of hallucinations and delusions can help reduce this anxiety.

Behavioral experiments
Delusions and hallucinations may be combatted by verbally challenging the clients' perceived
reality. One method is using behavioural experiments or 'reality testing', i.e. a kind of personal experiment where the client tests whether the delusions are real. In many cases it is difficult to talk a client out of their belief so it is better to set up a situation where they can test it. For example, if a client believes someone else is trying to harm them, ask them to keep a record of evidence to support this. So the client might record that a person in the street walked past deliberately looking away which reflects an intention to harm. Evidence collected in the experiments can then be discussed and used to debunk erroneous beliefs. This should help the individual to differentiate between the 'confirmed reality' and the 'perceived reality'

Behavioral activation
Schizophrenia is associated with motivational deficits such as social withdrawal and anhedonia (lack of enjoyment or pleasure found in previously enjoyed activities). These may be reduced by rewarding positive behaviours, such as becoming more socially active and expanding the range of pleasurable activities that the person is involved in. The person's sense of 'self' may also be addressed. For example, helping the client to recognise that there are more ways to define themselves than 'I am schizophrenic', which could be linked to feelings of marsinalisation and stigmatisation

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cognitive behaviour treatment eval AO3

Evidence from NICE
A strength of CBT is support from the National Institute for Health and Care Excellence (NICE). NICE (2014) conducted a meta-analysis of high quality studies of CBT (e.g. randomised controlled trials). The analysis showed that CBT was effective in reducing rehospitalisation rates for up to 18 months for people with schizophrenia and it also reduced time spent in hospital (8.26 days on average). CBT also reduced symptom severity and improved psychosocial functioning, both at the end of treatment and 12 months later.This is good evidence to support the value of CBT as a treatment for schizophrenia.

May not reduce symptoms
A weakness of CBT is that there is mounting evidence to suggest that it does not after all reduce symptoms or prevent relapse. For example, Peter McKenna and David Kingdon (2014) compared CBT with routine treatment or a control non-biological intervention and found that CBT was only superior in two out of nine methodologically rigorous trials. Furthermore, in
one of the studies that had a positive result the blinding procedure lapsed as the study unfolded, suggesting the results may not have been valid. This suggests that CBT may not be as effective as the NICE (2014) report
suggests.

Competing argument This said, meta-analyses using only quantitative data overlook the unique experiences of people in therapy, whereas case studies such
as William Bradshaw' (1998), which take an idiographic approach, demonstrate that a strong therapeutic alliance developed over many months can support the
process of personal recovery. This suggests that CBT can have value.

Drug-resistant clients
A further strength is support for CBT from studies of people who have not responded well to medication.
Elizabeth Kuipers et al. (1997) conducted a randomised controlled trial of CBT for schizophrenia and found that drug-resistant clients improved when given CBT which targeted their delusions and hallucinations. This is important because many people with schizophrenia do not respond to
antipsychotics, so it is useful to have a second line of therapy to offer.

Application to independent living
CBT can be used to develop important social skills so people can cope better with independent living and daily interactions. One of the strengths of CBT is that it can target ways to improve a person's quality of life by discussing and developing personal and social skills. This can be achieved through challenges to irrational thoughts which then enable the person to relate better to others. An adjunct treatment to CBT is the specific use of social skills training. This kind of approach offers a more long-lasting solution than drug therapy.

CBT does seem to reduce relapses and re-admissions to hospital according to nice in 2014 however the fact that these people on medication and having regular meetings with doctors would’ve expected to have that effect anyway

turkington et al 2006 found that it is highly effective and should be used as mainstream treatment for schizophrenia wherever possible

lengthy- takes months compared to drug therapy which leads to disengaged treatment as they don’t see immediate effects