Schizophrenia

TREATMENT PATH STAGE I: IDENTIFYING SCHIZOPRENIA | TREATMENT PATH STAGE II: REFERRAL | TREATMENT PATH STAGE III: ASSESSING AND DIAGNOSING SCHIZOPHRENIA | TREATMENT PATH STAGE IV: TREATING SCHIZOPHRENIA | TREATMENT PATH STAGE V: MONITORING AND REVIEWING | RESOURCES FOR CLIENTS

This Clinical Information Guide1 is one in a series of guides designed to assist caseworkers and supervisors in identifying and managing clients who need mental health services. These guides use the treatment pathways model,2 which outlines five stages to assist you in obtaining the best possible mental health services for your clients. Each guide is designed to highlight the primary casework task that needs to be accomplished at each stage, and to address common questions that you might have as you complete each task.

What are the five stages of the Treatment Pathways Model?

In the identification stage, you gather information concerning the identified problems, consult with your supervisor and the behavioral health consultant, and decide whether or not your client needs to be referred to a mental health specialist. In the referral stage, you follow established procedure by completing required documentation and selecting the appropriate mental health specialist. In the assessment and diagnosis stage, you assist the specialist by furnishing relevant information concerning your client. In the treatment stage, you work collaboratively with the clinician to identify treatment goals and secure the most effective treatment available for your client. In the monitoring and reviewing stage, you ensure that reasonable treatment goals are achieved.

TREATMENT PATH STAGE I: IDENTIFYING SCHIZOPRENIA

Primary Casework Task: To gather information to decide whether or not your client exhibits the symptoms of schizophrenia and to consult with your supervisor and the behavioral health consultant to determine if a referral for an evaluation or clinical intervention is needed.

What is Schizophrenia?

Schizophrenia is a chronic, severe, and disabling psychiatric disorder. People with schizophrenia suffer symptoms such as hearing internal voices not heard by others, or believing that other people are reading their minds, controlling their thoughts, or plotting to harm them. These symptoms may leave them fearful and withdrawn. Their speech and behavior can be so disorganized that they may be incomprehensible or frightening to others. Available treatments can relieve many symptoms, but most people with schizophrenia continue to suffer some symptoms throughout their lives; it has been estimated that no more than one in five individuals recovers completely.

How common is Schizophrenia?

Approximately one percent of the population develops schizophrenia during their lifetime - more than two million Americans suffer from the illness in a given year. Although schizophrenia affects men and women with equal frequency, the disorder often appears earlier in men, usually in the late teens or early twenties, than in women, who are generally affected in the twenties to early thirties.

What are the symptoms of Schizophrenia?

The principle symptoms of schizophrenia include psychotic behavior (hallucinations and delusions), disorganized thinking, and blunted emotional expression.

Hallucinations

Hallucinations are perceptions that occur without connection to an appropriate source. Although hallucinations can occur in any sensory form - auditory (sound), visual (sight), tactile (touch), gustatory (taste), and olfactory (smell) - hearing voices that other people do not hear is the most common type of hallucination in schizophrenia. Voices may describe the patient's activities, carry on a conversation, warn of impending dangers, or even issue orders to the individual.

Delusions

Delusions are false personal beliefs that are not subject to reason or contradictory evidence and are not explained by a person's usual cultural concepts. Delusions may take on different themes. For example, patients suffering from paranoid-type symptoms - roughly one-third of people with schizophrenia - often have delusions of persecution, or false and irrational beliefs that they are being cheated, harassed, poisoned, or conspired against. In addition, delusions of grandeur, in which a person may believe he or she is a famous or important figure, may occur in schizophrenia. Sometimes the delusions experienced by people with schizophrenia are quite bizarre; for instance, believing that a neighbor is controlling their behavior with magnetic waves; that people on television are directing special messages to them; or that their thoughts are being broadcast aloud to others.

Disorganized thinking

Schizophrenia often affects a person's ability to "think straight." Thoughts may come and go rapidly; the person may not be able to concentrate on one thought for very long and may be easily distracted, unable to focus attention. The person may be unable to connect thoughts into logical sequences, with thoughts becoming disorganized and fragmented. This lack of logical continuity of thought, termed "thought disorder," can make conversation very difficult and may contribute to social isolation.

Blunted emotional expression

People with schizophrenia often show "blunted" or "flat" affect. This refers to a severe reduction in emotional expressiveness. A person with schizophrenia may not show the signs of normal emotion, perhaps may speak in a monotonous voice, have diminished facial expressions, or appear extremely apathetic. The person may withdraw socially, avoiding contact with others; and when forced to interact, he or she may have nothing to say, reflecting "impoverished thought." Motivation can be greatly decreased, as can interest in or enjoyment of life. In some severe cases, a person can spend entire days doing nothing at all, even neglecting basic hygiene.

Phases of Schizophrenia

The symptoms of schizophrenia manifest themselves in different ways with different individuals. In general, however the course of schizophrenia can be characterized by three phases:

The boundaries between phases are not absolute, and vary from individual to individual. The majority of people with Schizophrenia alternate between acute and stable phases. Some people with Schizophrenia have only one severe psychotic episode; others have many episodes during a lifetime, but lead relatively normal lives during the interim periods. However, the individual with "chronic" schizophrenia often does not fully recover normal functioning and typically requires long-term treatment, generally including medication, to control the symptoms.

Is there risk of suicide or violence?

Suicide is a serious danger in people who have schizophrenia. People with schizophrenia have a higher rate of suicide than the general population. Approximately 10 percent of people with schizophrenia (especially younger adult males) commit suicide. Most individuals with schizophrenia are not violent; more typically, they are withdrawn and prefer to be left alone. People with paranoid and psychotic symptoms, which can become worse if medications are discontinued, may also be at higher risk for violent behavior. When violence does occur, it is most frequently targeted at family members and friends, and more often takes place at home.

Can children have Schizophrenia?

Children over the age of five can develop schizophrenia, but it is very rare before adolescence. Although some people who later develop schizophrenia may have seemed different from other children at an early age, the psychotic symptoms of schizophrenia - hallucinations and delusions - are extremely uncommon before adolescence.

What causes Schizophrenia?

There is no known single cause of schizophrenia, although it is likely to be caused by an interplay of genetic, behavioral, and other factors. For example, it has long been known that schizophrenia runs in families. People who have a close relative with schizophrenia are more likely to develop the disorder than are people who have no relatives with the illness. For example, a monozygotic (identical) twin of a person with schizophrenia has the highest risk - 40 to 50 percent - of developing the illness. A child whose parent has schizophrenia has about a 10 percent chance. By comparison, the risk of schizophrenia in the general population is about 1 percent.

Scientists are studying genetic factors in schizophrenia. It appears likely that multiple genes are involved in creating a predisposition to develop the disorder. In addition, factors such as prenatal difficulties like intrauterine starvation or viral infections and perinatal complications. Many studies of people with schizophrenia have found abnormalities in brain structure (for example, enlargement of the fluid-filled cavities, called the ventricles, in the interior of the brain, and decreased size of certain brain regions) or function (for example, decreased metabolic activity in certain brain regions). It should be emphasized that these abnormalities are quite subtle and are not characteristic of all people with schizophrenia, nor do they occur only in individuals with this illness.

TREATMENT PATH STAGE II: REFERRAL

Primary Casework Task: To complete the required referral process, including gathering supporting documentation, and to select the appropriate mental health specialist to assess, diagnose, and treat your client.

What kinds of mental health specialists can evaluate my client?

Psychologists (Ph.D., Psy.D.) , physicians (M.D., including psychiatrists), licensed clinical social workers (L.C.S.W.), and psychiatric nurses (R.N.) have the training and background to conduct an initial evaluation for schizophrenia. Once schizophrenia is diagnosed, your client should be evaluated by a physician to rule out the possibility of medical problems causing the schizophrenia and to be evaluated for medication.

These mental health specialists can be found at community mental health agencies, the psychiatry department of hospitals or clinics, employee assistance programs, health maintenance organizations, university or medical school-affiliated programs, state hospital outpatient clinics, family service or social service agencies, or private clinics.

TREATMENT PATH STAGE III: ASSESSING AND DIAGNOSING SCHIZOPHRENIA

Primary Casework Task: To assist the mental health specialist by furnishing relevant information concerning your client's mental health.

The first step to getting appropriate diagnosis and treatment for schizophrenia is a thorough diagnostic evaluation by a mental health specialist. The clinician will gather a complete history of symptoms, including when they started, how long they have lasted, how severe they are, whether the individual had them before and, if so, whether the symptoms were treated, and what treatment was given. The clinician will ask about alcohol and drug use. Further, a history will include questions about whether other family members have had schizophrenia and what treatments they may have received that were effective.

Sometimes people suffer severe psychiatric symptoms due to undetected underlying medical conditions. For this reason, a physical examination and laboratory tests should be done to rule out other possible causes of the symptoms before concluding that a person has schizophrenia. In addition, since commonly abused drugs may cause symptoms resembling schizophrenia, blood or urine samples from the person can be tested at hospitals or physicians' offices for the presence of these drugs. Because almost all individuals with schizophrenia require medication to manage their symptoms, once a diagnosis of schizophrenia is made, the individual will need to see a psychiatrist.

TREATMENT PATH STAGE IV: TREATING SCHIZOPHRENIA

Primary Task: To secure the most effective treatment available for your client's schizophrenia and to work collaboratively with the treating clinician to identify treatment goals and objectives.

What kinds of treatment are available?

Current treatment approaches attempt to reduce the symptoms of schizophrenia and to lessen the chances that symptoms will return. The type and intensity of treatment services depend on the phase of the illness. In all phases, treatment will involve both medication and psychosocial interventions.

Medications

Almost all individuals with schizophrenia will require antipsychotic medication. The large majority of people with schizophrenia show substantial improvement when treated with antipsychotic drugs, although these medications do not "cure" schizophrenia or ensure that there will be no further psychotic episodes. The choice and dosage of medication can be made only by a qualified physician who is well trained in the medical treatment of psychiatric disorders. The dosage of medication is individualized for each patient, since people may vary a great deal in the amount of drug needed to reduce symptoms without producing troublesome side effects.

A number of new antipsychotic drugs (the so-called "atypical antipsychotics") have been introduced since 1990. The first of these, clozapine (Clozaril®), has been shown to be more effective than other antipsychotics, although the possibility of severe side effects - in particular, a condition called agranulocytosis (loss of the white blood cells that fight infection) - requires that patients be monitored with blood tests every one or two weeks. Newer antipsychotic drugs, such as risperidone (Risperdal®) and olanzapine (Zyprexa®), are safer than the older drugs or clozapine, and they also may be better tolerated.

Antipsychotic drugs are often very effective in treating certain symptoms of schizophrenia, particularly hallucinations and delusions; unfortunately, the drugs may not be as helpful with other symptoms, such as reduced motivation and emotional expressiveness. Sometimes when people with schizophrenia become depressed, other symptoms can appear to worsen. The symptoms may improve with the addition of an antidepressant medication.

Patients and families sometimes become worried about the antipsychotic medications used to treat schizophrenia. In addition to concern about side effects, they may worry that such drugs could lead to addiction. However, antipsychotic medications do not produce a "high" (euphoria) or addictive behavior in people who take them. Another misconception about antipsychotic drugs is that they act as a kind of mind control, or a "chemical straitjacket." Antipsychotic drugs used at the appropriate dosage do not "knock out" people or take away their free will. While these medications can be sedating, the utility of the drugs is not due to sedation but to their ability to diminish the hallucinations, agitation, confusion, and delusions of a psychotic episode.

Antipsychotic medications reduce the risk of future psychotic episodes in patients who have recovered from an acute episode. Even with continued drug treatment, however, some people who have recovered will suffer relapses. In most cases, it would not be accurate to say that continued drug treatment "prevents" relapses; rather, it reduces their intensity and frequency. The treatment of severe psychotic symptoms generally requires higher dosages than those used for maintenance treatment. If symptoms reappear on a lower dosage, a temporary increase in dosage may prevent a full-blown relapse.

Are there problems adhering to medication treatment?

Because relapse of illness is more likely when antipsychotic medications are discontinued or taken irregularly, it is very important that people with schizophrenia work with their doctors and family members to adhere to their treatment plan. Good adherence involves taking prescribed medication at the correct dose and proper times each day and attending medication management appointments.

There are a variety of reasons why people with schizophrenia may not adhere to treatment. Patients may not believe they are ill and may deny the need for medication, or they may have such disorganized thinking that they cannot remember to take their daily doses. Family members or friends may not understand schizophrenia and may inappropriately advise the person with schizophrenia to stop treatment when he or she is feeling better. Physicians, who play an important role in helping their patients adhere to treatment, may neglect to ask patients how often they are taking their medications, or may be unwilling to accommodate a patient's request to change dosages or try a new treatment. Some patients report that side effects of the medications seem worse than the illness itself. Further, substance abuse can interfere with the effectiveness of treatment, leading patients to discontinue medications.

Fortunately, there are many strategies that patients, doctors, and families can use to improve adherence and prevent worsening of the illness. Some antipsychotic medications, including haloperidol (Haldol®), fluphenazine (Prolixin®), perphenazine (Trilafon®) and others, are available in long-acting injectable forms (called "depot") that eliminate the need to take pills every day. Medication calendars or pill boxes labeled with the days of the week can help patients and caregivers know when medications have or have not been taken. Using electronic timers that beep when medications should be taken, or pairing medication taking with routine daily events like meals, can help patients remember and adhere to their dosing schedule. In addition to any of these adherence strategies, patient and family education about schizophrenia, its symptoms, and the medications being prescribed to treat the disease is an important part of the treatment process and helps support the rationale for good adherence.

What About Side Effects?

Antipsychotic drugs, like virtually all medications, have unwanted effects along with their beneficial effects. During the early phases of drug treatment, patients may be troubled by side effects such as drowsiness, restlessness, muscle spasms, tremor, dry mouth, or blurring of vision. Most of these can be corrected by lowering the dosage or can be controlled by other medications. Different patients have different treatment responses and side effects to various antipsychotic drugs.

The long-term side effects of antipsychotic drugs may pose a considerably more serious problem. Tardive dyskinesia (TD) is a disorder characterized by involuntary movements most often affecting the mouth, lips, and tongue, and sometimes the trunk or other parts of the body such as arms and legs. It occurs in about 15 to 20 percent of patients who have been receiving the older, "typical" antipsychotic drugs for many years, but TD can also develop in patients who have been treated with these drugs for shorter periods of time. In most cases, the symptoms of TD are mild, and the patient may be unaware of the movements.

Antipsychotic medications developed in recent years all appear to have a much lower risk of producing TD than the older, traditional antipsychotics. The risk is not zero, however, and they can produce side effects of their own such as weight gain. In addition, if given at too high of a dose, the newer medications may lead to problems such as social withdrawal and symptoms resembling Parkinson's disease, a disorder that affects movement. Nevertheless, the newer antipsychotics are a significant advance in treatment, and their optimal use in people with schizophrenia is a subject of much current research.

Psychosocial treatments

Antipsychotic drugs have proven to be crucial in relieving the psychotic symptoms of schizophrenia. However, even when patients with schizophrenia are relatively free of psychotic symptoms, many still have extraordinary difficulty with communication, motivation, self-care, and establishing and maintaining relationships with others. Moreover, because patients with schizophrenia frequently become ill during the critical career-forming years of life (i.e., ages 18 to 35), they are less likely to complete the training required for skilled work. As a result, many with schizophrenia not only suffer thinking and emotional difficulties, but lack social and work skills as well.

It is with these psychological, social, and occupational problems that psychosocial treatments may help most. While psychosocial approaches have limited value for acutely psychotic patients, they may be useful for patients with less severe symptoms or for patients whose psychotic symptoms are under control. Numerous forms of psychosocial therapy are available for people with schizophrenia, and most focus on improving the individual's social functioning - whether in the hospital or community, at home, or on the job. Some of these approaches are described here.

Individual and group psychotherapy

Psychotherapy involves regularly scheduled talks between the patient and a mental health professional such as a psychiatrist, psychologist, psychiatric social worker, or nurse. This could be conducted individually or in a group with other people who have Schizophrenia. The goals of therapy for individuals with Schizophrenia are to improve medication compliance, which includes identifying side effects and warning signs of relapse, negotiating medical and psychiatric care, and expressing their medical needs to community agencies. Other goals include improved problem solving, goal planning, and social skills. Psychodynamic or insight-oriented treatments can be harmful if conducted when the individual is in the acute phase of the disorder.

Family therapy or family education

It is important that family members learn all they can about schizophrenia and understand the difficulties and problems associated with the illness. It is also helpful for family members to learn ways to minimize the patient's chance of relapse - for example, by learning the early warning signs or using different treatment adherence strategies - and to be aware of the various kinds of outpatient and family services available in the period after hospitalization. Family "psychoeducation," which includes teaching various coping strategies and problem-solving skills, may help families deal more effectively with their ill relative and may contribute to an improved outcome for the patient.

Self-help Groups

Self-help groups for people and families dealing with schizophrenia are becoming increasingly common. Although not led by a professional therapist, these groups may be therapeutic because members provide continuing mutual support as well as comfort in knowing that they are not alone in the problems they face. Family and peer support and advocacy groups are very active and provide useful information and assistance for patients and families of patients with schizophrenia and other mental disorders. A list of some of these organizations is included at the end of this guide.

Electroconvulsive Therapy (ECT) is sometimes used when medication and psychosocial interventions have failed. ECT is conducted in a medical setting and involves the administration of a short duration anesthetic, followed by medications to relax the muscles. Electrodes are then placed on the patient's scalp and an electric current is passed through them, producing a seizure, which lasts 30 to 45 seconds. Because muscle relaxants are used, there is generally little movement or chance of injury. The most common side effects of ECT are headache and transient memory disturbances; memory problems generally disappear over a few weeks to a few months. ECT is used more often in the acute phase than in other phases of Schizophrenia.

Vocational rehabilitation

The aim of vocational rehabilitation is to enable an individual to achieve the highest level of vocational functioning possible. Some of the kinds of vocational rehabilitation available include:

Supportive housing

Supportive housing is used for patients who do not live with their families and would benefit from supervision in their living arrangements. One of the most common types of supportive housing arrangements is the transitional halfway house, which is a residential facility that provides room and board and serves as a transition between the hospital and the community. Other supportive housing programs include long term group residences, which have on-site staff, and cooperative apartments, which have staff that visit regularly for oversight and guidance.

Does treatment vary according to the phase of schizophrenia?

The goals, types, and duration of treatment varies according to the phase of the disorder.

How do I collaborate with the mental health specialist and my client to design treatment goals?

Developing treatment goals is a critical step in the treatment process. Clear, objective treatment goals enable the client, family, and service provider to address the client's mental health needs. Treatment goals should reflect the phase of schizophrenia that the individual current experiences.

There are two broad kinds of treatment goals: Administrative and clinical. Administrative goals involve the completion or non-completion of services. Examples of administrative goals include the number of medication monitoring or psychotherapy sessions that a client attends. Clinical treatment goals address two domains related to a client's overall functioning: symptom or behavior change, and changes in daily functioning ability

You will need to collaborate with your client and the mental health specialist to create treatment goals that address your client's symptoms and the areas of functioning that are critical to your client fulfilling his or her service plan. You will need to work with the mental health specialist to determine the manner and frequency with which treatment goals will be measured.

TREATMENT PATH STAGE V: MONITORING AND REVIEWING

Primary Task: To ensure that you receive timely and appropriate documentation from the mental health specialist that reviews progress towards treatment objectives.

How do I know if treatment is working?

To determine whether or not your client's treatment is working, you will need to evaluate how well each treatment component is addressing each symptom or problem. For example, antipsychotic medication should reduce your client's hallucinations. Psychotherapy should address your client's social functioning and understanding of his or her illness. Anther measure of treatment effectiveness will be how well your client is able to function in the community when provided with necessary supports. Reports from friends, family, teachers, and employers will help you assess whether or not the treatment is working

Treatment Outcomes

What role do I play in monitoring my client's treatment goals?

Usually the mental health specialist will gauge the success of intervention services by observing changes in your client's behavior and functioning. Because of your extensive knowledge of the client's behavior, the specialist may ask you about the client's functional change in different areas. For example, the specialist may ask you about your client's ability to get along with peers or other family members.

If your client is not improving, you will want to talk with the mental health specialist or physician concerning factors in the client's life that could be complicating recovery. Perhaps after treatment began, additional life stress or change occurred in the client's life, such as the death of a loved one or a change of job.

It is important to note that individuals who have had many episodes of schizophrenia throughout their lives may need to continue treatment well beyond the time when their symptoms diminish, or indefinitely.

What kind of documentation should I expect from the mental health specialist?

You should expect quarterly treatment summaries that highlight your client's progress toward all administrative and clinical treatment goals. If you review a treatment summary and find that it differs significantly from your observations of the client, you will want to contact the mental health specialist to discuss your concerns. You will also want to contact the specialist if you believe that new goals should be added to your client's treatment plan.

RESOURCES FOR CLIENTS

Where can my client obtain information about schizophrenia?

There are numerous resources for information concerning the diagnosis and treatment of schizophrenia. Specialty clinics that treat schizophrenia are included in Appendix B of this Clinical Information Guide. Your clients can obtain information about schizophrenia by contacting the following agencies:

National Institute of Mental Health

Office of Communications and Public Liaison

Information Resources and Inquiries Branch

6001 Executive Boulevard, Rm. 8184, MSC 9663

Bethesda, MD 20892-9663

(301) 443-4513

nimhinfo@nih.gov.

American Psychiatric Association

1400 K Street, N.W.

Washington, DC 20005

(202) 682-6000

www.psych.org

American Psychological Association

750 First Street, N.E.

Washington, DC 20002

(202) 336-5500

www.apa.org

National Alliance for the Mentally Ill

Colonial Place Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201-3042
Phone: 1-800-950-NAMI (6264) or (703) 524-7600
www.nami.org

National Mental Health Association
1021 Prince Street
Alexandria, VA 22314-2971
Phone: 1-800-969-6942 or (703) 684-7722
www.nmha.org

National Alliance for Research on Schizophrenia and Depression (NARSAD)
60 Cutter Mill Road, Suite 404
Great Neck, NY 11021
Phone: (516) 829-0091

www.narsad.org

Treatment Path Stage Clinical Information Casework & Administrative

I. Identification of problem

Behavior of Individual with Schizophrenia:

· delusions (persistent false beliefs)

· hallucinations (hearing voices or

    seeing things)

· disorganized or incoherent

    speech

· extremely disorganized or

    catatonic behavior

· blunted emotion expression

Casework Tasks:

a) Obtain input from spouses, caregivers, and others who have on-going contact with client.

b) Observe client

c) Review clinical records

d) Consult with supervisor & behavioral health team

Administrative Task:

· Document in case record

II. Referral

Licensed mental health specialists that evaluate for schizophrenia are:

a) Psychiatrists (M.D.)

b) Psychologists (Ph.D., Psy.D.)

c) Licensed clinical social workers (LCSW)

d) Psychiatric Nurses (RN)

Administrative Tasks:

a) Complete referral to licensed mental health specialist.

b) Include relevant clinical and case records with your referral.

c) Document in case record.

III A. Assessment

Mental health specialist must:

a) Interview client and significant others (e.g., spouse, parent)

b) Review case and clinical records

Administrative Task:

· Ensure mental health specialist

    has all relevant casework and clinical records.

III B. Diagnosis

Diagnosis must meet DSM-IV criteria, which includes two or more of the following during a one-month period:

· delusions (persistent false beliefs)

· hallucinations (hearing voices or

    seeing things)

· disorganized or incoherent

    speech

· extremely disorganized

    behavior

· blunted emotion expression

Additional diagnostic criteria include:

· Significant impairment in social or occupational functioning since onset of symptoms

· Symptoms must persist for six

    months

If diagnosed, physical exam is required to rule-out other medical disorders and to provide baseline laboratory results for starting medication.

Administrative Task:

· Ensure mental health specialist

    has all relevant casework and

clinical records.

IV. Treatment

Treatment varies according to phase of disorder.

A. In acute phase the goals are to reduce psychotic symptoms, which involves:

1. Hospitalization for individuals who are suicidal, homicidal, or psychotic and unable to care for themselves.

2. Antipsychotic medication in nearly all cases. This is sometimes supplemented with antidepressants, mood stabilizers, or other medications.

3. Supportive, psychoeducational approaches for individual and family (could be in individual, group, or family modalities). Psychodynamic or insight-oriented approaches can cause relapse and should not be conducted.

4. ECT may be considered for individuals who do not respond to medication or can not tolerate it.

B. In stabilization phase the goals are to prevent relapse, facilitate continued reduction of symptoms, and help individual adapt to community.

1. Continue medications, usually at same dose for at least six months.

2. Day hospitalization or day treatment.

3. Individual or Group psychosocial treatment that is supportive, develops a relapse prevention plan, teaches basic life skills, and involves the family or social support system. Psychodynamic or insight-oriented approaches can cause relapse and should not be conducted.

C. In the stable phase the goals are to improve individual's level of functioning and quality of life, treat relapses, and address problems in treatment (for example, medication side effects).

1. Continue medication, possibly at a lower dose.

2. Outpatient individual or group psychosocial treatment focusing on improving basic living skills, social skills, and vocational skills. Insight-oriented approaches may be integrated depending on the individual.

3. ECT may be considered for individuals who do not respond to medication or can not tolerate it.

Casework Task:

Work collaboratively with mental health specialist to establish clear, measurable administrative and clinical treatment goals that assess your client's attendance and his or her change in:

    a) schizophrenic symptoms

    b) functioning in areas relevant to the case plan. These areas might include home, work, and relations with family and friends.

V. Monitoring & Review of

Treatment

Complete remission is uncommon. Most individuals will need medication and some psychosocial support indefinitely.

The frequency and method of

monitoring treatment goals depends on the severity of symptoms:

a) Medication -- Physician monitors by reports from client and significant others and by conducting laboratory tests.

b) Psychosocial treatments -- Mental health specialist collects data from client by interview and rating scales and from reports by significant others (including caseworker).

Casework Tasks:

a) Work with mental health specialist and client to evaluate progress toward treatment goals.

b) If necessary, work with specialist to revise treatment goals or to consider other kinds of treatment.

Administrative Tasks:

a) Obtain copies of quarterly, written treatment summaries from mental health specialist. Summaries should document client's progress toward clinical and administrative treatment goals, using standardized measures when appropriate.

b) Document in case record.


APPENDIX B: LOCAL RESOURCES

1 Portions of this Clinical Information Guide are adapted from Schizophrenia, a patient information guide published by the National Institute of Mental Health, and Practice Guideline for the Treatment of Patients with Schizophrenia, which is published by the American Psychiatric Association.

2 The treatment pathway for Schizophrenia is summarized in Appendix A.

TREATMENT PATH STAGE I: IDENTIFYING SCHIZOPRENIA | TREATMENT PATH STAGE II: REFERRAL | TREATMENT PATH STAGE III: ASSESSING AND DIAGNOSING SCHIZOPHRENIA | TREATMENT PATH STAGE IV: TREATING SCHIZOPHRENIA | TREATMENT PATH STAGE V: MONITORING AND REVIEWING | RESOURCES FOR CLIENTS