5.1.4 - Schizophrenia treatments
Learn how antipsychotic medication and cognitive behavioural therapy for psychosis work, what counts as evidence that they help, and why effective care considers symptoms, daily life and the person's preferences.
How antipsychotics change signalling
Antipsychotic medication is a biological treatment intended to reduce psychotic symptoms such as distressing hallucinations and delusions.
A neurotransmitter carries a signal between neurons by binding to a receptor, a protein that responds to it. Many antipsychotics act as dopamine D2 receptor antagonists: they occupy receptors and reduce dopamine's ability to activate them. The drug does not remove all dopamine from the brain. Reducing excessive dopamine signalling in relevant pathways can reduce the inappropriate importance given to otherwise ordinary events, helping reduce positive symptoms. This is a mechanism of treatment, not proof that every person's schizophrenia has one dopamine cause.
First-generation, sometimes called typical, antipsychotics include chlorpromazine and haloperidol. Their dopamine-blocking action helps explain both benefits and some unwanted effects. Dopamine also contributes to movement and hormonal regulation; blocking it in other pathways can produce movement problems or increased prolactin. A chemical can have different effects in different circuits, so “block dopamine” is not the same as “target only a hallucination”.
Second-generation, or atypical, antipsychotics often affect serotonin receptors as well as dopamine receptors. They are a varied group rather than one uniformly better treatment. Some have lower risks of particular movement effects but substantial risks of weight gain or metabolic problems. Clozapine is an example with an important role when adequate trials of other antipsychotics have failed; its use requires specialist monitoring. Some newer agents are dopamine partial agonists rather than simple antagonists. For the core comparison, the key taught biological mechanism is D2 antagonism, while these differences explain why drug choice matters.
Symptom management
Reducing symptoms and their impact without necessarily removing the original vulnerability to a disorder.
Benefits are judged over time, rather than inferred from immediate sedation. Feeling sleepy is a possible side effect, not the definition of successful treatment. Medication may make symptoms manageable enough for a person to work, maintain relationships or engage with psychological support, but negative symptoms and cognitive difficulties can remain.
Evidence and costs of medication
Effectiveness depends on which outcome is measured, for whom, and over what period.
An acute symptom trial asks whether symptoms improve during an episode. A maintenance trial asks whether continuing treatment reduces later relapse, the return or worsening of symptoms after improvement. In Leucht and colleagues' 2012 systematic review and meta-analysis, relapse at one year was reported for 27% receiving antipsychotics compared with 64% receiving placebo. These are group outcomes, not a guarantee for an individual. They support a useful maintenance effect while showing that relapse still occurred with treatment. Original review abstract.
Combining randomised trials is stronger evidence than simply observing that people who choose medication differ from those who do not: random allocation reduces selection differences. Nevertheless, maintenance trials commonly compare continuation with withdrawal after stabilisation. Withdrawal effects, differences among drugs and trial durations complicate inference about every possible long-term care situation. A lower relapse rate also does not by itself establish better employment, satisfaction or absence of side effects.
Movement effects can include restlessness, stiffness and involuntary movements; some effects can persist. Other concerns include sedation, weight gain and metabolic changes. These can affect dignity, physical health and willingness to continue. Adherence means following an agreed treatment plan. Difficulty adhering is not simply disobedience: unpleasant effects, access problems, forgetfulness and different beliefs about treatment can all matter. A treatment that works in a controlled trial can have less benefit when it is intolerable or unavailable in ordinary life.
NICE guidance treats medication as an individual therapeutic trial, with benefits, risks and physical health monitored and choices made jointly with the service user. This gives a concrete ethical principle: a clinically effective drug still requires informed discussion and review. It does not justify using medication merely to make a ward easier to manage. NICE CG178, sections 1.3.5–1.3.6.
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