Schizophrenia: The Changing Focus of Treatment

The focus of treatment in schizophrenia has changed tremendously a number of times since its clinical features were first described in the ‘modern’ literature by Kraepelin (1) and Bleuler (2) about a hundred years ago. The discovery of typical antipsychotics in the 1950s (3) heralded the change of approach from predominantly isolating patients in mental hospitals to effectively moving them back into the community (4). Nonetheless, in reality, those drugs were only effective at treating positive symptoms of schizophrenia and thus, for many years psychiatrists had to be contented with such symptom reductions, while patients had to endure severe side-effects including extra-pyramidal side-effects (EPSE). With the advance of atypical antipsychotics from the 1980s, the treatment paradigm of schizophrenia evolved further to focus on achieving ‘remission’ (5) that is, to effectively treat negative and mood symptoms, in addition to positive symptoms. Remission remained as the aim of schizophrenia treatment until recently while psychiatrists acknowledged that many patients remained with residual symptoms characterised by predominance of negative and cognitive symptoms and struggled to cope in the community. Of late however, there has been a wider recognition of failure of schizophrenia patients to attain psychosocial functioning such as independent living, ability to study and work, and relate to others in the community. Consequently, there is now a shift in treatment focus. Evidence-based psychosocial rehabilitation programmes have been developed aiming to improve functional outcome of schizophrenia (6-10). What these programmes have in common is that they purport an integrated non-parsimonious approach combining several evidence-based psychosocial interventions such as work-skills training, psychoeducation, family support groups, and cognitive remediation.  This approach had been shown to be effective in achieving a more global symptom reduction and functional improvement in meta-analyses (11).