Schizophrenia

Clozapine – The Medication People Hope Will Help

Schizophrenia can sometimes respond well to treatment. Someone might try a medication, find that voices, paranoia, disorganized thinking, or severe agitation begin to ease, and that they can gradually reclaim the pieces of their usual routine. But for others, symptoms persist despite what seems like treatment that should be optimal. When two attempts to get other medicines to work for the psychosis, two conscientiously-tried trials, have not worked well enough, clozapine usually becomes the next medication to consider.

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Clozapine Really Is Special

Clozapine became available in Europe in 1972 and was approved by the US FDA in 1989. It’s widely considered the most effective medicine for schizophrenia, especially treatment-resistant schizophrenia. “Treatment-resistant” means that two other medications have been tried and have not worked well enough. For many people, clozapine is the medication that finally brings meaningful relief after other medicines have failed. It can reduce persistent psychosis and, in some individuals, might also help lower the risk of suicide and severe aggression.

While Clozapine is a Powerful Medicine the Side Effects Can Be Awful

Clozapine is not an easy medication to take. That’s why, even though it’s considered the most effective medicine for schizophrenia, it’s usually not the first one tried. One might need regular blood tests since it can rarely sharply lower infection-fighting white blood cells. It could also cause constipation so bad that it can be fatal, excess salivation, sleepiness, weight gain, dizziness, metabolic problems, and seizures. Awful stuff. Early in the course of using clozapine it could prompt inflammation that could affect one’s heart. Such bad side effects are scary, but after someone has tried several others that didn’t work, risking such possible side effects might be worth it if clozapine helps a lot.

When the One That’s Supposed To Work, Clozapine, Falls Short

But even apart from the side effects, clozapine does not work well enough for everyone. Some patients get only partial relief. They might feel less distressed or be less likely to need hospitalization, but maybe they’re still hearing voices or troubled by false beliefs. Other patients cannot continue taking clozapine because they do get the side effects and can’t tolerate them. This presents quite a dilemma. There isn’t study-supported information on what to do next.

There’s a Name for the Problem: Clozapine-Resistant Schizophrenia

One could use the term clozapine-resistant schizophrenia when problem symptoms continue despite a giving it a good try to use clozapine. The term is just a description of the clinical situation that clozapine has been given a fair chance, yet the patient is still unwell and unhappy about it. Don’t take the term as a crystal ball predicting a sad future. Clozapine not working signals doctor and patient alike to go over the treatment plan and come up with a next step. It’s not a reason to stop searching for ways to improve life.

First, Make Sure the Clozapine Trial Was Fair

Before the doctor and patient decide that clozapine has failed to work as planned they need to ask themselves a few practical questions. Mr. Patient, have you taken it regularly? Doctor, did you increase the dose cautiously and did you take it high enough? Did you take the top therapeutic dose long enough that it should have worked? Are smoking, other medicines, illness, or missed doses changing the amount of clozapine in the bloodstream? These details outline the difference between a true lack of good effect as opposed to a treatment that was never fully tested.

Slow and Careful Clozapine Dose Increases

Clozapine is ordinarily started at a low dose and increased gradually. Such a schedule protects patients from potentially serious early side effects, including excessive sedation, dangerously low blood pressure, seizures, and heart muscle inflammation. “Start low and go slow” is a good clozapine protocol. Slow titration does, of course, mean that a person might spend too long a time below a helpful dose, so physicians do need to eventually try pushing the dose higher.

Why Clozapine Blood Levels Matter

The clozapine dose that you swallow is measured in milligrams, but how much you take doesn’t tell the whole story. Two people taking the same number of pills might well have very different blood concentrations of the medication, and blood concentration is what treats the psychosis. Smoking tobacco, for example, can speed clozapine’s breakdown, so one needs higher dose. Caffeine, on the other hand, can boost the level in the blood, so a lower dose might work. Other medicines, infections, and genetic differences can affect blood levels. A clozapine blood test can tell whether the level was high enough to assess its benefit fairly.

Clozapine’s Three-Month Benchmark

There’s a large group of schizophrenia experts working together around the world to solve barriers to successful psychosis treatment. The group is called the Treatment Response and Resistance in Psychosis Working Group, acronym TRRIP. They recommend to physicians to allow at least three months of treatment after an adequate clozapine blood level has been reached before concluding that it hasn’t worked. They provide specific levels that are considered “adequate’.

A Higher Clozapine Blood Level Is Not Automatically Better

If the clozapine blood level is below their adequate needed level, and if side effects permit, the first recommendation from this group is to consider a careful gradual dose increase. This is not a contest to reach the highest possible number. Higher clozapine levels might increase the likelihood of side effects, including seizures, and the benefits beyond a certain point are uncertain. The goal is just an individually appropriate and tolerable exposure for that specific patient, guided by symptoms, side effects, blood levels, health monitoring, and shared doctor-patient decision-making.

The Treatment Response and Resistance in Psychosis Working Group – A Survey

The recommendations from the group are a consensus opinion, not a magic formula. The Wagner paper didn’t present new clinical data supporting one specific “next step”. Instead, the authors surveyed this group of experienced international specialists about what they would recommend in a situation where solid guiding research evidence is limited. The participating experts each have extensive clinical experience and they come from multiple countries. Their answers are useful, remarkably so, but they should be understood as an informed consensus of opinion, not as a guarantee that the same approach will help every individual.

Match the Treatment Plan to the Patient’s Main Problem

One important message from the group is that “not enough response” can mean very different things. Persistent hallucinations or delusions are not the same as severe social withdrawal, lack of motivation, suicidal thinking, aggression, depression, medication side effects, or trouble functioning at work or home. A good treatment plan begins with identifying the patient’s most urgent remaining problem. That matters because the best-supported next step will probably differ depending on which symptoms are causing the greatest upset for the patient.

Adding a Second Psychosis Medicine to Clozapine

For continuing positive symptoms like distressing voices, paranoia, or strongly held false beliefs the Psychosis Working Group most often endorsed adding another antipsychotic while continuing clozapine. The two drugs to add that had the most votes were oral aripiprazole and or amisulpride. Amisulpride is not available in the US and some other countries. The recommendation was not to lower clozapine but to add the second medication, aripiprazole, and not change the clozapine dose unless one has to for safety.

Why A Combination with Clozapine Is Considered

The logic behind combination treatment is that medicines that treat psychosis don’t all act in exactly the same way, that is, they have differing mechanisms of action. Clozapine by itself has an unusual pharmacologic profile, a “rich pharmacology”, as they say. A second medicine might add a useful new effect for a person whose psychosis has improved on clozapine, but only partly. That’s the benefit, but combining medications also increases complexity. There might be more side effects, more interactions, more pills, and more uncertainty about which one is helping or harming. Adding the second drug needs to be a deliberate, thought-through, monitored trial, not a hurried “stick it on” automatic layering-on of drugs.

There Was an Add-On to Clozapine That the Group Didn’t Endorse

The Treatment Response and Resistance in Psychosis Working Group did not reach consensus for routinely adding medicines for depression to clozapine to treat persistent positive symptoms. The group also did not endorse a long list of speculative add-ons sometimes promoted online or in off-the-cuff discussions. It’s not that every option that they didn’t endorse is necessarily useless, it just means the group did not find sufficient agreement or persuasive evidence to recommend that specific treatment for this specific clozapine situation.

ECT Is a Modern Medical Treatment

When persistent positive symptoms remain severe, the Psychosis Working Group also supported considering electroconvulsive therapy, or ECT, as an addition to ongoing clozapine. Sadly and unfortunately, ECT has a public image shaped by old movies and frightening historical accounts, but modern ECT is a carefully-controlled medical procedure performed under general anesthesia with full muscle relaxation. It intentionally produces a brief seizure while the patient is closely monitored by an experienced medical team. Today’s ECT is so gentle that it’s often recommended for refractory depression in the elderly and with pregnant women.

ECT and Persistent Psychosis

For clozapine-resistant positive symptoms (e.g., hallucinations, delusions, paranoia), the Psychosis Working Group supported a course of about 12 ECT treatments, commonly delivered three times each week for four weeks. If a person improves, continuation or maintenance ECT might be considered if needed to help preserve the gain. It’s well understood that ECT is not a trivial intervention, and that it can cause temporary confusion or memory problems, among other risks. Yet for someone with severe, ongoing psychosis despite clozapine, it can be a life-saver, so a serious and reasonable option to discuss.

Clozapine Plus Therapy Remains a Great Plan

Medication is not the entire treatment plan for schizophrenia whether symptoms are mild or intense. One cannot just toss a pill at someone and magically they’re well. For persistent positive symptoms the Psychosis Working Group recommended cognitive-behavioral therapy for psychosis (CBTp), as an additional approach. Apart from the Group’s recommendations, it might have been a good plan to start cognitive-behavioral therapy for psychosis when that first medication was tried, way before clozapine. Cognitive-behavioral therapy for psychosis doesn’t require a patient to try to dismiss a perception that feels real. Instead, it can help them examine interpretations, notice triggers, reduce distress, develop coping strategies, and regain practical control over daily life.

Sixteen or More Sessions of Cognitive-behavioral Therapy for Psychosis

One does have to give psychotherapy enough time to be work. The Treatment Response and Resistance in Psychosis Working Group were of the opinion that one needed at least 16 Cognitive-behavioral Therapy for Psychosis sessions to expect a beneficial reduction in persistent positive symptoms. We would emphasize the “at least”, as AT LEAST. There’s the danger than a physician or patient will have 16 sessions and decide that’s “one and done” for therapy. Nope! If there’s a partial benefit one should keep going. I suppose if there’s no benefit, zero, zilch, zip benefit, after 16 sessions, then one might stop.

Plain Vanilla Cognitive-behavioral Therapy for Negative Symptoms

Then there are the negative symptoms, low motivation, little emotional expression, not talking much, avoiding social interaction, nothing is fun. The Working Group recommended regular Cognitive-behavioral Therapy (that is, not the version designed for psychosis) and help with psychosocial interventions. Negative symptoms are really badly disabling even without the positive symptoms like hallucinations and delusions. Treating negative symptoms needs approaches that focus on routines, goals, skills, relationships, and meaningful activity.

Psychosocial Approaches the Bedrock Foundation for Success

“Psychosocial” interventions are brain changing and life changing. “Psychosocial” is not just touchy, feely, get-a-hug stuff. It can rewire your brain circuits. Things like family education and support, social-skills role-playing, help with employment or education, confirming housing and daily structure, substance-abuse treatment if needed, dietary education, and physical exercises and activities. These fold into a comprehensive medical care program. Psychosocial interventions are not done instead of needed medical care. These therapeutic interventions treat areas of health that a drug, by itself, cannot help. Patients with schizophrenia and psychosis often suffer with isolation, disrupted routines, unemployment, strained relationships, and the practical consequences of years spent ill.

Just When You Thought Everything Was Going in the Right Direction – Suicide

This is where psychosis and schizophrenia become a fatal disease. Like sudden cardiac death, suicide can appear. So, if suicidal thoughts or worse, behaviors toward suicide, become the central concern, the Psychosis Working Group went a different direction, not just upping clozapine or adding another drug. They emphasized the above mentioned psychosocial approaches and regular Cognitive-behavioral Therapy as additions to clozapine. Indications of immediate danger require urgent, supportive, individual medical assessment. Family members, friends, even acquaintances need to listen carefully and take statements seriously about wanting to hurt oneself or wanting to die. Drag the person to emergency help when safety is in question rather than waiting to see whether the feeling passes.

Psychosis Plus Aggression – A Dangerous Mix

The old psychoanalysts used to say that suicide is anger turned inward and aggression is anger turned outward. That’s pretty abstract and theoretical. Treating aggression needs action, not theorizing. Move and move quickly. When aggression has emerged as the key problem, the Psychosis Working Group said to consider an add-on mood stabilizer or adding another antipsychotic alongside clozapine, while also employing psychosocial care. We would reverse that order. First, aggressively jump in to contain the aggression and urgently look for the cause or trigger. Has it appeared because of untreated psychosis, or fear, or trauma, or substance use, or delirium, or medication side effects, or conflict, or an unsafe environment? It’s not just a character flaw and should never be assumed to be a simple character flaw and not actively treated. A careful but quick assessment of what is driving the behavior is essential for choosing treatment approaches that protect everyone’s safety.

These Experts Didn’t Know How To Use Repetitive Transcranial Magnetic Stimulation

Our esteemed Treatment Response and Resistance in Psychosis Working Group drew a blank on this one. Or, to be kind, they didn’t agree on a consensus recommendation for clozapine-resistant schizophrenia. We’re talking about Repetitive Transcranial Magnetic Stimulation (rTMS). It seems like a near-miraculous treatment but for now it remains an area of research rather than a clear next step. Repetitive Transcranial Magnetic Stimulation uses magnetic pulses from a device held near the head, outside the scalp, to influence specific targeted brain circuits. It doesn’t need any type of anesthesia and it doesn’t need to cause a seizure. The medical research community has studied it in recent years for several psychiatric conditions, including some symptoms of schizophrenia.

If Clozapine Seems Not To Be Working, Don’t Quickly Stop It

It’s a “knee jerk” reaction. Gee, clozapine doesn’t seem to help, let’s just stop it. This is simplistic (or we might pejoratively say stupid) thinking. Just because clozapine doesn’t eliminate all the symptoms of treatment resistant schizophrenia is not, by itself, a reason to abruptly abandon it. The Psychosis Working Group really advised against stopping it because positive or negative symptoms are still present. Even partial benefit can be important. If the patient has fewer crises, less terror from voices, better sleep, less aggression, or more ability to participate in treatment, that’s enough. Stopping clozapine can lead to relapse, so any decision to reduce or discontinue it must be carefully planned and the taper monitored closely.

Stop Clozapine If…

There are times when one has to stop clozapine even if it seems to be working. Stop it if it’s causing side effect that the patient can’t tolerate. If there’s not a dose that seems to provide some benefit with the side effects still moderate, stop it. Stop it if it causes a bad reaction, like a serious allergic reaction. (Anaphylaxis can be fatal.) Stop it if it causes some other safety concern. These decisions are made for each specific patient by the patient and their physician. Stop it immediately if an urgent medical situation demands it. Otherwise, clozapine needs to be tapered gradually since stopping it too quickly can allow the rapid return of the symptoms it is meant to treat. The doctor can plan a gradual taper.

Precision Medicine Means Individualized Care

No distant expert or group or journal article can dictate the best next step for any one specific patient. As the doctor and patient discuss the ongoing symptoms, past treatment responses, medical conditions, other necessary medications, likes and dislikes, and access to therapy and to ECT, a next step forward will emerge. And, the decision will evolve and maybe change at each visit.

Schizophrenia Not Helped by Clozapine Presents a Real Challenge

When one discovers that their psychosis is not treated well enough even by clozapine it can be disheartening. It’s time for a doctor-patient “sit down and discuss” meeting, an honest and open back-and-forth on what do we do next. It leaves behind the comfort of solid, study-proven medical science and moves forward into medical expertise and patient preferences. The groundwork must be laid for a carefully planned trial to try to optimize clozapine, think through targeted augmentation, agree on a yes or no on ECT, get the right psychotherapy with the right psychotherapist in place, find and shore up life’s practical supports, and track progress or lack thereof closely. The goals are relief, stability, connection, and a more livable life.

Reference

Wagner E, Kane JM, Correll CU, Howes O, Siskind D, Honer WG, Lee J, Falkai P, Schneider-Axmann T, Hasan A; TRRIP Working Group. Clozapine Combination and Augmentation Strategies in Patients With Schizophrenia: Recommendations From an International Expert Survey Among the Treatment Response and Resistance in Psychosis (TRRIP) Working Group. Schizophrenia Bulletin. 2020;46(6):1459–1470.

Maybe Schizophrenia Won’t Disappear Anytime Soon

Part I. How Schizophrenia Is Treated Now

The thing is, the approach to treating schizophrenia has not changed much in the past 75 years.

The Start of a Revolution in Treating Schizophrenia

A Bit of Pharmacology History

In 1950, a big breakthrough changed how schizophrenia was treated. Chlorpromazine (Thorazine), a medicine that helped ease symptoms of psychosis, was discovered by accident. Before this, treatments were often harsh and ineffective, like insulin coma, lobotomy, heavy sedation, or early, crude forms of electroconvulsive therapy (ECT). (Modern ECT is much gentler and safer and even suitable for pregnant women and the elderly.)

Chlorpromazine paved the way for a flood of new medications: haloperidol (Haldol) in 1958, then others like trifluoperazine (Stelazine), thioridazine (Mellaril), fluphenazine (Prolixin), and clozapine (Clozaril). By the 1990s, newer medications like risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel) came into use. These drugs often improved patients’ lives, though they came with side effects, sometimes really awful side effects.

Today’s Medicine Today – No Great Shakes

Today, the standard approach to treating schizophrenia starts with a detailed evaluation. Doctors gather information about symptoms, trauma history, substance use, and medical history. They assess the patient’s mental and cognitive state, as well as risks for suicide or aggression. If psychosis is confirmed, an antipsychotic medication is almost always prescribed.

Wake Up, Medical World – Speed Is Important

But here’s the problem: this process is often slow. Weeks, months, or even years can pass as doctors try one medication after another, with patients remaining in a psychotic state as one after another medication is tried. The mindset is often, “We are trying.”

However, these past several years medical science has realized something alarming. Psychosis is toxic to the brain. It’s like brain poison. The longer someone stays psychotic, the harder it becomes for their brain to recover. This discovery has shifted the way we think about treating schizophrenia.

Oh, By the Way, Welcome

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Part II. New Information & A New Treatment Plan for Schizophrenia

With Realizing that Psychosis is Toxic to the Brain, a Revolution in Schizophrenia Treatment Starts

Why Treatment Needs to Start Fast

Since psychosis damages the brain, it’s critical to treat it immediately. At the first signs of trouble, effective medication treatment must begin. Waiting for a confirmed diagnosis could cause irreparable harm to the person’s brain. It’s similar to the situation in medicine when an antibiotic for an infection is started before the exact bacteria is identified. Acting quickly prevents the illness from getting worse. It’s important to start even if details need to be worked out later.

Start Your Engines and Hit the Accelerator

This rapid-response approach works for people of all ages, from children to the elderly. Early treatment improves the chances of a full recovery from psychosis and reduces the likelihood of future psychotic episodes, hospitalizations, and life disruptions. It’s the difference between someone being able to date, finish school, and hold a job versus struggling with a major lifelong disability.

Polish That Crystal Ball and Predict the Future

Predictions are hard to make, especially about the future. (Some attribute this wisdom to the famous baseball player Yogi Berra, others say it came from the pen of renowned author Mark Twain.) But what if, instead of waiting for that first psychosis to appear, we could predict who is likely to experience psychosis even before it happens? That’s where biomarkers, medical clues like family history, brain health markers, and genetic background, come into play. These markers are helping doctors identify people at high risk for psychosis so that they can intervene early.

Healthy People with Healthy Brains Taking Antipsychotics

But that’s where this grand plan hits a dilemma. Not everyone at high risk ends up having psychosis. Studying these individuals may help us understand why some people develop the condition while others don’t, even with similar risk factors.

A Reader from Wyoming Asks: Does this actually work, or is it all just theory?

This reader, who said they lived in Wyoming, wrote to say that that whole mental illness schizophrenia area seems medically ill-defined. Maybe it’s all nonsense. So, it feels like speculation on nonsense to propose that an illness we’re not even sure exists in the first place can be eliminated by drugs.

We appreciate all feedback from each of our readers, and thank the reader for writing. That said, we clearly would take issue with this reader. We view psychosis as a well-established brain disorder, and further, a disorder that is toxic to the health of the brain. But our reader might have a valid point that is not immediately obvious.

Using the term “schizophrenia” has been criticized by learned and astute physicians and medical researchers. (See below the reference to the paper, “Eliminate schizophrenia”.) Even in medicine, even in psychiatry, the label “schizophrenia” is used to refer to many, many medical conditions. And the symptom of psychosis is seen in people who don’t have “schizophrenia”. They argue that the word is just a label and not a useful diagnostic term. It’s not a disease one can nail down with any certainty. These experts feel that medical science and practice should refer to the basket of problems that land under the schizophrenia label with a broad, ill-defined basket label, like “psychosis spectrum illnesses” until the science can tease out what is what with some better level of certainty.

Part III. The New Plan Hits Rough Water

At First It Seemed Like Such a Great Idea.

But, Treating People Who Are Well, Who Might Never Get Sick?

New discoveries often come with challenges. How’s this for a challenge. About half of the young people identified as high-risk for psychosis never develop it. That’s quite a hurdle to jump for this idea of treating the first episode of psychosis before it starts. Some high-risk-for-psychosis Individuals have been followed for over ten years to see if they ever become psychotic. Nope, they did not, or at least about half of them did not. But, many of that half who never become psychotic did fall ill with other psychiatric conditions, such as depression and anxiety.

Antipsychotics for Healthy People

You see the dilemma that this whole situation creates. The logical reasoning of this path is that we should give antipsychotic medications to people at high risk BEFORE they become psychotic. But, half of them will never become psychotic. Should we give these potentially harmful medicines for psychosis to healthy people who might never become sick? No, probably not. The drugs used to treat psychosis do have side effects. Some of them are really problematic side effects. Like weight gain, diabetes, and heart problems. Plus, just the act of telling a healthy person that they’re at high risk for some day becoming psychotic would upset about anybody. Such “news” could ruin a person’s whole outlook on life.

It’s One Thing If They’re Already Psychotic…

So, let’s back up for a moment. This is an easier decision if psychosis is already present. It’s clear that an existing and present psychosis, even the first hints of a real psychotic episode, need to be treated immediately. This immediacy is backed by strong medical evidence. But there’s little evidence for preventing a psychosis with antipsychotics just because an individual is identified as a high-risk. When there isn’t any hint of psychosis and they’ve never had a psychotic episode, why do anything? Though some experts advocate for pursuing less risky interventions in these identified-high-risk people, like psychotherapy or social support. It might be that these therapies are just as effective at preventing psychosis without the side effects.

Then There Is That Risk of Depression and Anxiety

Here’s another perspective. As we said above, among the group of high-risk individuals who never develop psychosis, over half have other psychiatric disorders, mostly depression and anxiety. Though antipsychotics were designed to treat psychosis, they can often work really well to treat anxiety or depression. This raises the possibility that early treatment might prevent other psychiatric disorders, not just psychosis.

Oh, The Ethics of It All

Coming at this dilemma from an ethical perspective provides new questions but really no new answers. Treating someone who isn’t psychotic but is at high risk is tricky. It might be defensible to treat someone without their consent when they are psychotic. Someone in the middle of a psychotic episode might not even know who they are, or where they are, or what’s happening around them. It’s hard to say whether a truly psychotic individual can even give authentic informed consent for accepting to take a medication. Or, refusing it. It’s like saving the life of someone unconscious after a car crash. One just saves the life absent any consent or refusal. We save their life. But on the other hand, unlike a psychotic person who might not be capable of informed consent or refusal, individuals who are not yet psychotic can decide for themselves. They are able to weigh the potential benefits against the risks and make their own informed choice.

Part IV. Well, Good Grief, Now What Do We Do?

We’re in a Quandary: And, Current Studies are Giving Mixed Results.

Is There a Middle Ground Approach?

So, what’s the best way forward? Imagine someone at high risk of psychosis due to their family history, their genetic makeup, and their adverse life experiences. Their doctors present them with a set of options. Maybe watchful waiting with regular mental status monitoring. Or perhaps starting a therapy (like Cognitive Behavioral Therapy). Would they like to involve family members in this decision. Finally, would they like to start a medicine for preventing psychosis.

Could The Safest Option Be Opting for the Medicine?

Some argue that if someone is at extremely high risk, starting medication might be the safest option. For example, a woman at high risk might take an antipsychotic and avoid a future psychotic episode altogether, allowing her to live a normal life. Assuming any side effects are mild, this could be a great option.

Tailor-Made, Bespoke, for Clothes That Fit

Bottom line, there’s no one-size-fits-all solution. One cannot grab a dress or shirt off the rack and have it always be just right. It’s a medical debate that balances the promise provided by early intervention and a better outcome against the risk of over-treatment. Ultimately, individuals must be fully informed and then empowered to make their own decision, maybe starting with less invasive approaches like therapy.

 

When Is The Medication Route Absolutely Necessary?

We are left with the one clear mandate. if someone is already experiencing psychosis, immediate and aggressive treatment with medications is essential. Antipsychotics, combined with education, therapy, and social support, are the best way to protect the brain from the toxic effects of psychosis. Without medication, the other interventions are unlikely to succeed.

The Ultimate Goal is Health

The goal remains the same: to reduce the impact of schizophrenia on someone’s life and help them to live fuller, healthier lives. While the road is still uncertain, the commitment to finding better solutions continues.

Helpful Links:

From the National Alliance for the Mentally Ill – Early Psychosis Intervention

From the U.S. National Library of Medicine – Early intervention in psychosis: concepts, evidence, and future directions

Jennifer L Zick, Brandon Staglin, and Sophia Vinogradov. “Eliminate schizophrenia” in the journal Schizophrenia Research in 2022.

A Reader Asked: This article is responding to a reader’s question, asking:

When Can I Get Off Treatment for Schizophrenia?

One of our Canadian readers sent in the question: “When Can I Get Off Treatment for Schizophrenia?” A great question. This question is like a gold mine with many nuggets of information waiting to be uncovered. It’s an opportunity to look at schizophrenia treatment and medication safety. Let’s explore at least a few of the possible answers.

Get Off Your Treatment for Schizophrenia Immediately?

Given that schizophrenia is a lifelong medical condition requiring medication for a lifetime, the idea of stopping one’s medication immediately might seem radical. But there are times when you need to stop it immediately (and call your doctor and/or head for the nearest hospital emergency department). There are uncommon side effects of the medicines commonly used to treat schizophrenia that are dangerous, cannot be reversed, and could be life threatening. For example, allergic reactions, heart rhythm problems (QT interval prolongation, torsades de pointes), thromboembolism, seizures, stroke, and pancreatitis. These are important and we cover them in more detail below. But if one of these side effects occurs, call your doctor immediately for advice.

Another “Get Off Your Treatment for Schizophrenia Immediately” Answer

This answer is not about medication. As with any disorder affecting the brain, it’s helpful to work with a “guide” since at times your brain is not at it’s best. This helper person might be viewed as a guide, or an educator, or a therapist or psychotherapist. Whatever you call this person, he/she is a “support person” to help you through the rough spots of life. Also, when things are good, to work with you to prepare for the next rough spot. Because that’s how we all experience life, a series of rough patches with smoother sailing in between. If this person is no help at all, or even worse, just another problem person in your life, just stop. Find a new therapist. There are many good therapists, even some great ones. Respect yourself enough to not stay with a lemon therapist thinking you can make lemonade.

When Can I Get Off Treatment for Schizophrenia? Soon!

Soon, but not today. There are medical conditions for which the person needs to take a medication for the rest of his/her life. Type 1 diabetes, for example. The patient needs insulin. Without insulin for a while, they die, as did all type 1 diabetics before 1922. Or high blood pressure. Without treatment, it might take a decade or two, but high blood pressure will kill you with a stroke or heart attack. Medication for high blood pressure is usually needed for the rest of your life. Schizophrenia is another one. You need to take the right medication forever. So you need a medication that you can take, that doesn’t make you sick, that you can tolerate. So if you’re taking a medication that you can’t tolerate or that you don’t like, that’s not going to work. Talk to your doctor.

Finding the Right Medication for the Rest of Your Life

People argue about the best exercise program to stay healthy. Some say aerobic exercise like jogging, running, or dancing. Others swear by weightlifting, like chest presses and biceps curls. Others like flexibility and balance, like yoga and tai chi. But wisdom says the best exercise is the one you will do and keep doing. The same is true of your medication for schizophrenia. The best medication, the absolutely best medication, is the one that you will take regularly and keep taking forever. To find that right medication might become hard work. It can be a challenge, it might take time and trial and error. So if you don’t like your medication, talk to your doctor about changing it. Work with her to find the best one. And, if you feel your doctor can’t work with you to do this, find a new doctor.

When Can I Get Off Treatment for Schizophrenia? Back To Stopping Your Medication Immediately

Above, when we listed the medical emergencies for which you should stop your medications immediately, we said we would cover these reasons in more detail. Below is that detail.

We mention below calling “the emergency number“. For the U.S. and Canada this is 911, for the UK it’s 999. Ireland is 112 or 999. In New Zealand it’s 111 and In Europe and India it’s 112. In Australia it’s 000.

Back To Stopping Your Medication Immediately – Allergic Reaction

Any food, any medication, any substance, can cause an allergic reaction. This is not just a feeling that you don’t like the medication or that it gives you a headache. We mean a specific IgE-mediated allergic reaction. (IgE is immunoglobulin E.) A real allergic reaction to your medication for schizophrenia, a severe hypersensitivity reaction, can progress to “anaphylaxis”. The symptoms can come within minutes. Symptoms like hives and itching and flushed skin, wheezing and difficulty breathing, a weak, rapid pulse, nausea, dizziness, and fainting. This is life-threatening; it can kill you. You need to go to a hospital emergency department. And don’t take another dose of your medication until your doctor reviews your medical situation.

Back To Stopping Your Medication Immediately – Heart Rhythm Problems

There are a couple of heart rhythm problems of grave concern. One is called “QT interval prolongation.” The other is called “torsades de pointes.” Neither one, as you can see, is everyday conversation. But here’s the deal. You know that old expression, “What you don’t know won’t hurt you.” Well, it’s not true in these situations. Either of these heart rhythm problems can kill you whether you know about them or not.

What the heck is QT Interval Prolongation?

QT interval prolongation can make heart beats chaotic and can cause sudden heart death. So, if you’re still alive to notice the symptoms, call your doctor, stop your medication, and get help; you are better off than some people. The symptoms of possible QT interval prolongation are lightheadedness, weakness, passing out or fainting, and palpitations (palpitations means being aware of your own heartbeat), chest pain, or too fast a heartbeat. The QT interval is the time between electrical heart beats. Too long is not good. While older people and women are at a higher risk, having your QT interval change to too long can happen to anyone.

Okay, So, What the heck is torsades de pointes?

Torsades de pointes is a heart rhythm problem that is related to the prolonged QT interval problem described above. The symptoms of torsades de pointes are a fast heartbeat, lightheadedness, and feeling faint. If not treated as a medical emergency torsades de pointes can result in a sudden heart attack and death. There are mentions in the medical journals that thioridazine (Mellaril®), ziprasidone (Geodon®), and intravenous haloperidol (Haldol®) were most often associated with torsades de pointes. (“Torsades de pointes” is a French phrase for “twisting of the points”, referring to the heart beat points on an ECT [electrocardiogram, heart rhythm tracing]).

Once More on Stopping Your Medication Immediately – Thromboembolism

When a blood clot (thrombus) forms in your leg, the symptoms will be pain in your calf or thigh, leg swelling, your skin will feel warm, and on your leg you’ll see light red or purple streaks. If a piece of the clot breaks off (embolism) and gets to your lungs (this is the part that could be fatal), you’ll have shortness of breath and rapid breathing, rapid heart rate and chest pain, and might get lightheaded or faint. There’s a lot information in medical journals to say that the medications used for schizophrenia can, at times, cause leg blood clots. And, a piece of clot can break off and go to your lungs. Again, if you think you might have a thromboembolism, call your doctor. He’ll probably have you stop your medication and go right to a hospital emergency department.

Yet Again on Stopping Your Medication Immediately – Seizures

Like the adverse reactions above, it’s rare. But it can happen. You could have a seizure, also called convulsions. Almost all of the medications that are helpful for schizophrenia can increase the risk of someone having a seizure. Some of these medications increase the risk more than others. Risperidone (Risperdal®), haloperidol (Haldol®), molindone (Moban®), fluphenazine (Prolixin®), pimozide (Orap®), and trifluoperazine (Stelazine®) are less likely to cause seizures while chlorpromazine (Thorazine®) and clozapine (Clozaril®) are more likely to cause seizures. But any can cause a medically dangerous seizure, and once you have one you don’t want to have another. As before, if you have had something strange happen and you or someone else thinks it might have been a seizure, call your doctor. She’ll probably want to see you and do an EEG test (brain wave test).

More on Stopping Your Medication Immediately – Stroke

It’s also very rare, but it seems that the medications for schizophrenia can cause a stroke. The symptoms of a stroke vary. For example, a stroke might cause a sudden weakness of an arm and leg on one side of the body, or just an arm or just a leg, or part of the face. Speaking might become difficult with words hard to say or talking that make no sense. Or, the people around the person having a stroke might see that the person looks confused. Or, that they cannot understand the conversation. Vision might go bad or even sudden blindness in one eye, or both eyes. It you are the person who has had the stroke it’s unlikely that you will be the one to call the emergency medical number, but someone needs to call it. And to call the doctor for the person having the stroke.

One Last Thing on Stopping Your Medication Immediately – Pancreatitis

Once again, this is very rare, but the use of the medicines for schizophrenia can cause pancreatitis. The symptoms of pancreatitis are pain in the upper stomach area, maybe that is felt all the way through to the back, and maybe worse after eating. Symptoms might include a fever, a rapid heart rate, nausea and vomiting, and it might hurt if someone touches the stomach area. This side effect might be more likely with olanzapine (Zyprexa®), quetiapine (Seroquel®), risperidone (Risperdal®), and ziprasidone (Geodon®) than with other medications. It’s important to call your doctor but this might not be the same kind of urgent medical emergency like the conditions above. Whether or not it’s an emergency depends on how much you hurt. If the pain is really bad get to a hospital emergency department.

When Can I Get Off Treatment for Schizophrenia?

So, returning to the question, when can I get off my medication (or therapy) for schizophrenia? If you’re on a good medication that works well and that you can tolerate long term, and if you’re seeing a good therapist, don’t ever plan to stop either. Like Type 1 diabetes, schizophrenia is a lifelong condition. If you can get everything set in place for yourself, your life can be better. Stopping good medications that work well will let the next psychosis happen. And, psychosis is toxic to the brain. With each episode of psychosis your are less likely to get well when you restart a medication. And just the right therapist can be hard to find. If you’ve found her or him, stay in therapy. That’s your guide for life’s journey.

Helpful Links:

The Mayo Clinic on Schizophrenia Diagnosis and Treatment

The Mayo Clinic on Medicine Allergic Reactions

National Institutes of Health on Heart Reactions to Psychotropic Drugs

British Journal of Psychiatry on Medication and Venous Thrombosis

National Center for Biotechnology Information on Antipsychotic Medication and Seizures

NIH on Stroke Risk with Antipsychotic Use

National Library of Medicine on Acute Pancreatitis and Antipsychotic Use

Walking with You Through Treatment

When I sit across from someone hearing the word “schizophrenia” for the first time, I’m not thinking about receptors and scan results. I’m thinking about a life that just swerved off the road, and about how we can coax it back, inch by inch, without losing the person along the way.

Schizophrenia is a medical illness of the brain, as real and physical as diabetes or high blood pressure, but it attacks the parts of us we recognize as “who we are.” Treating it is not about turning someone into a “zombie”; it’s about protecting their thinking, their relationships, their future. My job is to be brutally honest about the difficulty of that work and equally honest about the hope that still exists, even when the path has been long and full of detours.

Welcome to the Neuroscience Research and Development Consultancy website. Have a question or a comment? Send it to us at: Comment@NeuroSciRandD.com We’ll answer if we can.

Why We Treat Early and Hard

As we said on our Schizophrenia page, we now know something crucial that earlier generations of psychiatrists did not fully appreciate: psychosis itself is toxic to the brain. Every untreated or under‑treated episode leaves a kind of chemical and structural “bruise,” making future episodes easier to trigger and harder to treat.

That’s why early intervention in psychosis programs exist, and why we push to recognize and treat the very first signs quickly and aggressively. When we shorten the time between the beginning of psychotic symptoms and effective treatment, people tend to have better long‑term functioning, fewer relapses, and more chance to stay in school, work, and relationships.

This is the core of the long‑term hope: if we can consistently catch psychosis early, treat it intensively, and support people for the first several years, we may dramatically reduce how many individuals go on to develop chronic, disabling schizophrenia. We are not there yet, but the trend of research is pointing in that direction.

Medications: Finding the Right Fit

Most people with schizophrenia will need medication, often for the long haul, the way a person with severe diabetes needs insulin. That’s a hard truth, and it’s okay if you don’t like hearing it. But the other side of that truth is that we now have a very large toolbox.

There are older “typical” antipsychotics and many newer “atypical” ones, each with its own profile of benefits and side effects: some are more calming, some more energizing, some fairly neutral. We use that to our advantage. If you are pacing all night and can’t sleep, a more sedating medication might be a blessing; if you are flat, withdrawn, and exhausted, a more activating one might help you engage again.

Sometimes we hit on the right drug early; sometimes we don’t. What I ask of patients and families is stamina: the willingness to keep working with me through trial and error, because once we find a medication that keeps psychosis quiet and is tolerable, staying on it can protect the brain and your life plans over years, not weeks.

When Standard Treatment Isn’t Enough

Roughly a third of people with schizophrenia do not respond well to the first couple of standard medications; we call this treatment‑resistant schizophrenia. That phrase sounds like a verdict. It isn’t. It’s a flag that we need to change our strategy.

Clozapine remains the most effective medication we have for many people whose symptoms have not improved with other drugs. It can reduce hallucinations and delusions, help with suicide risk, and sometimes bring someone back when nothing else has worked, but it requires regular blood monitoring because of rare but serious side effects. For the right patient, though, it can feel like finally getting traction after years of spinning the wheels. See our specific page on Clozapine.)

Even beyond clozapine, there are augmentation approaches under study and in use: adding medications that modulate glutamate or serotonin systems, targeted psychotherapy, neuromodulation strategies, and careful, evidence‑based combinations of antipsychotics. These are not miracle cures, but they are reasons not to give up when the first lines have failed.

What’s New Now: A Turning Point

For decades, almost all antipsychotics worked the same way. They blocked dopamine receptors. That’s changing. Recently, the FDA approved a medication called xanomeline-trospium (Cobenfy), which targets cholinergic receptors instead of the usual dopamine pathway. It offers a new mechanism for controlling symptoms, and researchers are working to understand which patients benefit most and how best to fold it into real‑world treatment.

Other novel drugs are in late‑stage development or early approval: agents like milsaperidone (Bysanti), newer serotonin-dopamine modulators, and medications such as brilaroxazine and LB‑102 that aim to improve not just positive symptoms (hallucinations, delusions) but also negative and cognitive symptoms. Several muscarinic modulators and M4‑focused compounds are being studied as well, hoping to calm psychosis with fewer movement or metabolic side effects.

For families who have watched someone they love struggle through multiple medications, hospitalizations, and side effects, this pipeline is not abstract; it is the possibility that the next drug we try will work differently enough to finally help where others have failed.

Looking Ahead: Can We Prevent Schizophrenia?

A question I hear, usually whispered, is: “Doctor, if we’d caught this earlier, could we have stopped it?” The honest answer is that in some people, early, intensive treatment of psychosis can prevent a first episode from becoming a long‑term, disabling illness, and in many others it can soften the trajectory and preserve more functioning.

Early psychosis programs that combine medication, psychotherapy, family education, school or work support, and skills training have shown better quality of life and symptom control than usual care. The more consistently we can deliver that kind of care from the very beginning, the closer we get to transforming schizophrenia from a life‑dominating disease into a serious but manageable condition. And even, for some, to preventing chronic schizophrenia from ever fully taking hold.

Will we completely eliminate schizophrenia? Not in the immediate future. But each step, such as screening young people earlier, shortening the time from first symptoms to treatment, expanding access to effective therapies, and developing medications that protect thinking and motivation, moves us away from inevitability and toward prevention.

More Than Medicine: Rebuilding Daily Life

Medications quiet psychosis, but they do not rebuild a life on their own. Many people with schizophrenia struggle with “negative” symptoms (such as a lack of motivation, emotional flatness, social withdrawal) and “cognitive” symptoms (like trouble focusing, organizing, remembering). These are often what keep someone from finishing school, holding a job, or maintaining relationships, even when the voices have faded.

Here, structured therapies matter: social skills training, cognitive remediation, supported employment and education, and family interventions that teach everyone how to navigate stress and relapse warning signs. Occupational therapy and day programs can help rebuild routines and confidence. Even simple, steady physical exercise, for example, walking most days of the week, has evidence for improving mood, cognition, and overall functioning.

If you are a patient, a parent, a partner, or a friend, you are not supposed to figure all of this out alone. A good treatment plan puts together medications, therapy, skills training, and community support into something that feels like a path, not a maze.

A Word of Hope at the End of a Hard Road

If you are reading this after years of trying medications, after emergency rooms and locked units and nights you thought would never end, talk of “hope” can sound hollow. I understand that. The hope I’m talking about is not a promise that if you just “try harder” everything will be fine.

It is the quieter, sturdier hope that comes from seeing new treatments arrive after decades of stagnation, from watching patients who were once stuck in revolving‑door hospitalizations finally get several stable years, from early‑intervention teens who finish college instead of disappearing from their own lives. It’s the hope that even if your schizophrenia has been “treatment‑resistant,” it is not resistant to every new idea, every new medication, every new support we can bring.

My commitment, and the commitment I hope you feel from any doctor you work with, is simple: we will keep walking with you, adjusting, learning, and using every tool, every current tool and every merging discovery, to protect your mind and your future as best we can.

List of Medications

At the bottom of this page is a long list of medications for schizophrenia.

Helpful links

The National Institutes of Health on Schizophrenia

A Current Treatment Options paper on Treating Negative Symptoms

The Mayo Clinic on Schizophrenia

Schizophrenia Information from the American Psychiatric Association

The National Alliance on Mental Illness on Schizophrenia

Medication List

Here is a (near complete) list of the schizophrenia medications available in the U.S.

• quetiapine (Seroquel) – calming, sedating x
• aripiprazole (Abilify, Ability Maintena, Ability Asimtufii, Opipza) – oral and injectable – balanced between activating and calming x
• risperidone (Risperdal, Risperdal Consta, Perseris, Uzedy, Risvan, Rykindo) – oral and injectable – balanced between activating and calming x
• ziprasidone (Geodon) – calming, sedating x
• lurasidone (Latuda) – activating, energizing x
• clozapine (Clozaril, FazaClo, Versacloz) x
• olanzapine (Zyprexa, Zyprexa Zydis, Zyprexa Relprevv) – oral and injectable – calming, sedating x
• olanzapine and samidorphan (Lybalvi) – x
• clozapine (Clozaril, Versacloz) – calming, sedating x
• chlorpromazine (Thorazine) – calming, sedating x
• paliperidone (Invega, Invega Sustenna, Invega Trinza, Invega Hafyera, Xepilon, Erzofri) – oral and injectable – not activating or sedating x
• perphenazine (Trilafon) x
• asenapine (Saphris, Secudo [transdermal]) – calming, sedating x
• trifluoperazine (Stelazine) – activating, energizing x
• pimozide (Orap) – activating, energizing
• molindone (Moban) – calming, sedating
• fluphenazine (Prolixin) – oral and injectable – calming, sedating x
• xanomeline and trospium chloride (Cobenfy) – x
• lumateperone (Caplyta) – x
• amisulpride (Barhemsys) – x
• milsaperidone (Bysanti) – x
• iloperidone (Fanapt) – calming, sedating x
• loxapine (Loxitane, Adasuve) – calming, sedating x
• thioridazine (Mellaril) – calming, sedating
• brexpiprazole (Rexulti) – not activating or sedating x
• aripiprazole lauroxil extended-release Injection (Aristida, Aristida Initio) – activating, energizing x
• cariprazine (Vraylar) – activating, energizing x
• haloperidol (Haldol) – oral and injectable – activating, energizing x
• thiothixene (Navane) – calming, sedating x
• reserpine (Raudixin, Serpalan, Serpasil) – But reserpine is such a problematic medication that it probably should not be used. It has adverse effects such as severe depression, significant hypotension, exacerbation of asthma, peptic ulceration and hemorrhage, and extrapyramidal (muscle tremor and spasm) side effects.

If you think we’ve missed a good one, let us know.

The Good News About Schizophrenia

There really is good news about schizophrenia and its treatment. It might be possible to eliminate schizophrenia altogether, as you’ll read in these pages. The modern medical science in this area is about stopping schizophrenia before it starts. And the medications available to treat existing schizophrenia keep getting better. New approaches with medications seek to treat the positive, the negative, and the cognitive symptoms, not just the psychosis. So take heart that it’s all good and getting better. As always, we remain on your side to praise what works, debunk anything that doesn’t work, and advocate for better medical care and better health outcomes.

Welcome to the Neuroscience Research and Development Consultancy website. Have a question or a comment? Send it to us at: Comment@NeuroSciRandD.com

Defining Schizophrenia: It’s a Brain in Trouble

Schizophrenia is a medical condition, a brain disorder. The brain changes caused by schizophrenia change how a person shows emotions, how they think, what they believe, what they hear, and how they behave. It creates a new world that only that one person can fully experience, and it’s scary.

Getting Help for Schizophrenia Is Not a Do It Yourself Project

Schizophrenia is a serious medical condition, a clinical situation that needs the best of medical care. Below we describe symptoms of schizophrenia. It’s not a medical condition that you can identify on your own, by yourself. As with any other medical disorder, you need to see a physician, preferably a physician with good training, a lot of experience with treating it, a good heart, and a good bedside manner. The physician has to be someone who can see the signs of schizophrenia correctly, ask the needed questions, and do the right tests and scans. And then, once all the information is in, offer her opinion on whether this is schizophrenia or some other illness. Then, in discussion, design a person-specific treatment plan.

Beginning at the Beginning – Early Symptoms of Schizophrenia

Early on, that is, when a person’s illness first starts, it might just be that “something” has changed. You might not be able to put your finger on exactly what, but something’s definitely different. It’s hard to get very specific here because the first symptom can appear over a few weeks, or a few months, or a few years. It’s different for each person. It might be something quirky, like coming up with a new belief about something that seems out of character, that makes little sense. (And this change is not the healthy exploration of adolescence.) It’s different. The early signs might be comments on hearing something, but each time, no one else can hear the sound, noise, or voice. The person might seem “deep in thought” too much or too often when they’ve never been like this before.

The Common Symptoms of Schizophrenia

“Positive symptoms” are the easily seen changes of schizophrenia, the fixed false beliefs (believing something that’s clearly not true), hearing voices that no one else hears, and the scattered thinking discussed below. “Negative symptoms”, the things that are missing with schizophrenia, are described below, too. The fixed false beliefs are the delusions. The voices are the hallucinations.

Schizophrenia’s New Onset of Fixed False Beliefs (Delusions)

A person with the early signs of schizophrenia might start believing things or ideas that seem odd and unusual and that don’t make sense. Like believing that their best friend has turned against them, or that the characters on TV are talking to them. Or they might turn enthusiastically religious or might start believing that they have special powers. Special powers like, for example, that they can think their way out of trouble. And you, as a reasonable person, mighty try to explain to them that they’re being unreasonable or unrealistic, or just silly. But they don’t get it and don’t believe you. In response they get angry, or quiet, and it’s clear that they don’t believe you.

Schizophrenia and the Voices That Aren’t There (Hallucinations)

This whole area about hearing voices is a big one. The person hears someone speaking. The speaking is not some faint voice far away and it’s not a voice that they believe might or might not be there. They know it is there. To them it’s a clear voice, one that’s right here, as though someone is standing next to them talking right into their ear. Except, there’s no one there and no one else can hear the voice. And as with the beliefs, if you try to convince them that there is no voice, they won’t believe you, because they can hear the voice. They hear the voice, they know someone is speaking. It’s not just thoughts in their head, it’s absolutely real to them. A very upsetting part, sometimes the voices tell them to do things, “command hallucinations”. Seldom are the commends to do something good.

Schizophrenia’s Foggy-minded Scattered Thinking

This part of the disability of schizophrenia is supposedly new to medical science as of the past twenty-five years or so. Actually, that’s not true.  Dr. Emil Kraepelin described it in the people with schizophrenia that he was treating over a century ago, but medical science “forgot” about it for about seventy-five years, focused on the psychosis. At first the person’s thinking becomes a bit scattered. And since we know how someone is thinking by how they’re speaking, their speech is scattered. We’re not talking about complete gibberish. It’s speaking in a way that’s a bit less well constructed with connected sentences. And for this person that we know, it’s out of character, not the way they usually would have spoken.

Schizophrenia’s Symptoms on What’s Not There – The Negative Symptoms

If you know a person well these will be easy for you to recognize. The individual doesn’t have their usual spark and flash about life. For example, a person doesn’t get excited about a situation or event that usually would really be great for them. For example, if they’ve always been an avid movie buff and not they’re not interested in a great new movie release. Or, they like the person with an upcoming birthday and usually they like parties but are blasé about the party. They’d rather skip it. They just don’t want to do anything active and social. Even fun things. They might not talk about much and might be reluctant to attend social events.

One of our readers asked:      

Doesn’t the schizophrenia know he’s sick? How can he not know?

Well, maybe, early on in the start of the changes the person will realize it. But, as the disorder progresses, usually at some point along the way the difference between what’s real and what’s not blurs. Then the person doesn’t know they’re sick. (See our free page on the side effect you can’t tell your doctor.) There’s another concern. What if it’s not schizophrenia? What if it’s just a reaction to a medicine for allergies, like a steroid? What if it’s a thyroid problem? What if it’s a toxic environmental exposure, like an insecticide or herbicide? An experienced physician needs to get the history, talk to the person, run the needed tests, and then make the correct diagnosis. One needs to get thyroid levels, other hormone levels, brain scans and maybe x-rays, a good medical history, and a good physical exam to understand the situation.

Symptoms of Schizophrenia In Women vs. In Men

There’s usually not much difference in the symptoms of schizophrenia between women and men. Maybe one difference is “inappropriate emotions”. This was found in a big study (1526 patients) of women and men with schizophrenia in the U.S. and India. In the study a history of “inappropriate emotions” meant that the person showed emotions that just didn’t fit the situation. And more women than men had a history of showing these inappropriate emotions, but the difference wasn’t large. Forty-two percent of the men and 55% of the women had it, so the difference was actually close to an even 50/50 split.

There Are Other Differences Between Men and Women with Schizophrenia

In this same study done in the U.S. and India there were other gender differences. The study had 395 men and 240 women in the U.S., and 480 men and 403 women in India. One difference was the course of the illness over time. Younger women (pre-menopause) had better course of the illness, meaning a less awful experience, than men. Men with schizophrenia were less likely to be married that the women. And, the women were likely to have more children than the men. Here’s a link to the study report: Women vs. Men – Symptoms of Schizophrenia Research Paper in Psychiatric Investigations.

Schizophrenia Is a Common Medical Condition

Schizophrenia is really common. Worldwide, about 77 million people have schizophrenia. It’s one of those medical conditions that equally crosses all the artificial social divisions that we human beings have constructed, affecting rich and poor, intelligent and challenged, all ethnicities, and any genders. And it’s about equal in men and women. An equal opportunity brain disorder.

Schizophrenia is a Brain-based Condition

Schizophrenia is a medical condition that affects the brain. As is discussed on our page Your Mind & Your Brain, all of the areas of our body are interconnected. So, in addition to the brain, schizophrenia affects many other organ systems like the immune system and the endocrine system (endocrine as in diabetic tendencies).

Schizophrenia is a Medical Condition

While we think this point is clear from the above discussion, we wanted to convince ourselves that we had tried to make it crystal clear: schizophrenia is physical. It’s as physical as a missing arm or leg. It is real, based in brain tissue changes. Here’s the problem. Many people use the word “mental”, as in mental illness, to mean not real. People equate “mental” with the phrase “all in your head” and use this terminology to mean imaginary. This use of the word “mental” is unfortunate and just plain wrong. Schizophrenia is not some vague, hazy thought or emotion just floating about in someone’s mind or head (or brain). It is corrupted brain hardware circuitry, hard wiring and circuits gone wrong in a person’s brain.

We Do Live in our Brain

As we’ve said, schizophrenia is a brain problem. That’s a big problem because we live in our brain. There is such a thing as mild schizophrenia, but it’s rare. (Maybe mild schizophrenia will be more common in the future.) But for now, schizophrenia is usually bad. People with schizophrenia hear voices that others don’t hear. They might view what’s going on around them in a different way. And because of the way their brain’s working they might make social mistakes and anger others. So, after a while, they start avoiding people. Why stay around people when they’re always angry? People with schizophrenia can become nervous, afraid, and upset. They might accidently upset others by making “strange” or nonsensical remarks. There are good medications that will help. It also helps to be in a secure, safe place.

We Need Better Medications for Schizophrenia

Everyone with schizophrenia and their family and friends would agree that we need better medications. Today’s best medications are huge advances over the best medications of 10 years ago. And those medications were better than the ones of 20 years ago. And those 20-years-ago medications were again incredibly better than the ones from 50 years ago. But today’s medications are still not good enough. Most people with schizophrenia never return to the way they were before the illness started. We need to fix that.

The Ongoing Explosive Revolution in Schizophrenia Knowledge and Research

We have to call the current rate of progress an explosive revolution in schizophrenia knowledge and research. For those of us in these research areas it’s really exciting. Physicians can now recognize signs in childhood that indicate the risk for eventual schizophrenia, twenty years before the psychosis starts. There are also newly found symptoms that become obvious just before the beginning of the first psychosis. We have a much better understanding of the way the disorder changes through a person’s life after that first episode. All the new information put together gives us an entirely new view of schizophrenia.

Seeing Schizophrenia Before It Begins

People have early changes in the way they behave for a period of time before the first clear signs of positive symptoms appear. People studying these changes aren’t certain how far before full psychosis the early signs can be seen. It could be that these early signs can be seen years before the obvious positive symptoms hit. As we commented above, it’s even possible that these first early signs can be seen in toddler years or infancy. Scientists are pursuing research all around the world to find out more. Many now believe that if we could tell early enough who is going to get schizophrenia we might be able to prevent it altogether.

Psychosis Is Toxic to the Brain, Making Schizophrenia Worse

The various nerve cell, nerve circuit, and chemical transmitter changes in the brain that result in psychosis are toxic to the brain. It’s like some toxic environmental exposure inside the brain. The changes damage the brain in a way that makes ongoing and worsening psychosis more likely. And, the longer the psychosis continues, the worse the toxic effect gets. The result of this situation is that if early signs of psychosis start and the psychosis is not treated quickly, it gets worse and is harder to treat. And the longer it goes untreated, the worse the condition will become and the more and more difficult it becomes to treat. In such a situation it certainly will likely never go away completely.

Schizophrenia Lasts a Lifetime

Schizophrenia a chronic medical condition. It lasts all through one’s life. In the old days, before we had the better medications we have now, when someone was sent to an residence hospital for schizophrenia they usually stayed in-hospital for the rest of their life. With today’s medications and other treatments the condition can improve to the point of people being almost symptom-free. A sad fact here is that too often people feel so well that they stop their medication and, as a result, their wellbeing falls apart. True, they will improve again when they restart their medication. But each episode of psychosis is toxic to the brain, so the improvement with restarting medication will likely not bring them back to the place they were before they stopped the medication.

Diagnose and Treat Schizophrenia Immediately and It Might Go Away

As we said above, in schizophrenia starting and stopping medication is an real bad idea. (See our free page on Treating Schizophrenia.) It’s likely that the psychosis makes itself worse, that is, psychosis is toxic to the brain and makes it easier for more psychosis to occur. Allowing any psychosis to persist for very long can set up the person for a lifetime of worse illness than need be. This means that if the first early symptoms start and the disorder is quickly treated and treated really well immediately, it might go away. Even if it doesn’t go away completely, the individual is likely to get better and have a milder course throughout his life.

Can We Wipe Out Schizophrenia?

So maybe if we can identify people on the path to develop schizophrenia, jump in with aggressive treatment as soon as the first signs appear, and keep the treatment going, we could wipe out schizophrenia altogether. Eliminating schizophrenia is a goal of everyone close to the condition: physicians, scientists, patients, family members, and friends. And we’re getting close. See our free page on Treating Schizophrenia.

Schizophrenia’s Causes are Complicated and Varied

There are a couple of life situations that greatly increase the risk for schizophrenia. One of these situations is everything a person goes through from the start of pregnancy to today, for example, events during fetal life while Mom is pregnant. The other situation is your ancestors, specifically the genes you inherit. What genetics did you inherit from mom and dad, grandparents, and other ancestors? As all the parts of life’s experiences and genes mix together, you can understand that schizophrenia in one person might be different from schizophrenia in another individual. This means that there is not just one disorder, “schizophrenia”, but many, many similar disorders, the “schizophrenias”, each a bit different. And, while these different schizophrenias might look similar, they are not. Yes, it does get confusing.

The Baby in the Womb and Schizophrenia

We have no control over what happens to us while our mothers are pregnant with us. Many situations that affect the developing baby can occur. Damage to a developing baby is one possible cause of schizophrenia even though the disorder does not appear until teenage years or in young adults. These problem influences on a baby’s well-being include a mother’s temporary diabetes while she is pregnant, any bleeding that she has during pregnancy, and events that can go wrong in labor and delivery like too little oxygen, an emergency C-section, and low birth weight. Another possible problem is infections that a mother has during the middle part of her pregnancy. Or a mother’s high stress levels during this time. These situations might lead to additional problems for the baby. These effects during the middle 3 months on the forming baby could double the risk of developing schizophrenia.

Schizophrenia Does Indeed At Times Run in Families

Schizophrenia can and sometimes does run in families. Families with one family member with schizophrenia are more likely to have other family members with it. Or, consider adopted children born to biological parents with a genetic risk for schizophrenia. They seem to have the same risk for getting schizophrenia in their new, adoptive home as they would have had if they had stayed in the home of their biological parents. So here it’s the genes, not the childhood environment. Schizophrenia also runs in families that have family members with bipolar disorder (manic depression). So, these two conditions are genetically linked in some way.

Helpful links:

NIH, National Institute of Mental Health – The NIH/NIMH on Schizophrenia

National Library of Medicine, MedlinePlus – MedlinePlus on Schizophrenia

The Mayo Clinic on Schizophrenia

American Psychiatric Association on Schizophrenia

National Alliance on Mental Illness on Schizophrenia