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Treating schizophrenia with dedicated, long-term care

Vijaykumar Harbishettar |

Schizophrenia is a severe and enduring mental illness that affects one percent of people all over the world. The illness usually starts between mid-teens to mid-twenties, that means between year 10 in Education and the early years in employment.

The illness may also have its onset when a person in the 40s or later, termed late-onset schizophrenia. The illness is characterised by disruption in the process of perception of senses, especially hearing and also in thinking.

Perceiving a sensation, usually hearing multiple voices that occur in the absence of anyone around is termed hallucination. The voice quality is like that of a normal person, but the only difference is that this happens in the absence of any real person speaking.

Therefore, for this person, such voices are real. These voices could be abusive and hostile causing irritability. The person – because of preoccupation with the voices – will not able to concentrate and have a social interaction.

The person rarely complains of hearing voices as abnormal and does not believe their origin is from an ill mind. There is abnormality in experience of thinking also, as the person believes he or she is being conspired against with people watching or following them.

Some patients have barricaded themselves because of fear when the severity of illness increased. The voices could also command to harm oneself or others and the person may act on these instructions. In simpler terms, some of these experiences are similar to dreams but with the person being fully awake and alert.

The patient’s kith and kin notice changes in behaviour – from gradually not getting involved in conversations or dialogue, seeking to remain aloof or quiet, being preoccupied with thoughts or seen mumbling or talking to oneself or as if in a conversation with invisible people around.

The person may express suspicion, believing there is a conspiracy against him or her and may stop trusting people. Then he/she becomes suspicious of phone calls, believes he/she is being tracked via cameras or being followed. The person would search for evidence to substantiate these fears and may even try and destroy objects like phones and TV sets.

The person can become hostile, irritable and abusive towards the family. The belief that the neighbours are conspiring against the person are also common and patients have knocked on their doors, had arguments, threatened and even complained to police. The helpless angry neighbours in turn argue with family members. Overall, there is a decline in performance in academics and also neglect of one’s self.

Commonly there is refusal to see a doctor or psychiatrist. The person may throw tantrums and become enraged if persuaded to consult a psychiatrist. Some families yielding to demands of the suffering person, may themselves meet and request a psychiatrist for a home visit or seek other means of getting the person treated, thereby in a way putting barriers in treatment.

Such initial gentle approaches by families, with a view to calm down the patient, may help rarely in preserving trust, but they will cause unwarranted delay in initiation of treatment. Untreated symptoms may further reduce chance of recovery or good improvement.

The illness can hinder the patient’s acquisition of social and life skills. Some memory-related, problem-solving abilities and judgment will get affected. By starting treatment early, getting quality care at home through motivated care-giving parents or spouses, many patients can complete their education or continue to perform in their employment.

Human Rights must be respected in persons with mental illness also. The New Mental Health Care Act of 2017 is due to come into force on 7 July 2018. Psychiatrists have to work within the framework of this Act.

If a person at the request of the family is examined and certified by two psychiatrists as having a possible mental illness that poses a threat to himself/herself or to others, and lacks competency to decide to seek treatment, then the person can be brought and treated as an in-patient in a psychiatric hospital against his/her wishes for a restricted period. The person will have the right to appeal against such detention.

Psychiatrists generally do attempt to treat patient with family members’ help at home and do try the least restrictive approach but it all depends on the severity of the illness, level of trust and family support.

Unfortunately, schizophrenia needs long-term treatment, though some people may make good recovery. Many symptoms can be treated or controlled. The focus switches from treating the illness to recovery phase, to make the person lead a more independent life by way of rehabilitation care.

There are several antipsychotic preparations available that are prescribed in various forms such as tablets, syrups, injectables and also injections that can be given as a depot which stay and act for weeks together. All medications have side effects that need to be discussed and monitored. The rule is to get a larger ‘benefit’ to ‘side effects’ ratio.

Since most persons do not believe they are ill, they refuse to take medications that are necessary to reduce their strange experiences. It is the trusting therapeutic relationship with the regular psychiatrist and the presence of the motivating care-giving family member that will ensure the treatment is adhered to. With many awareness programmes, caring family members and even at times the persons themselves are now coming forward and seeking treatment and continuing care.

The writer is a Consultant Psychiatrist and Ad-hoc Faculty in the Department of Psychiatry at National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore.