Internet Mental Health


Recovery From Schizophrenia

Individuals with schizophrenia and their families have defined that recovery from schizophrenia should involve:

  • Functional (occupational and social) remission:

    • "Employment/education: Returning to work/school/homemaking."

    • "Fulfilment of duties and responsibilities: Sons or daughters being loving, helping with housework, and attending social gatherings. In addition, husbands financially supporting their families, and wives taking care of their children and doing the expected homemaking."

    • "Independent functioning: Taking care of their personal needs without being dependent on or having the help/assistance of others."

    • "Social functioning: Socializing and having meaningful interpersonal relationships: having social skills (having manners, e.g., greeting others); having friends to talk to or spend time with; attending and participating in family and social functions; getting married; being reunited with or repairing broken relationships with spouses and family members."

  • Symptomatic remission:

    • "Symptom control: Eliminating hallucinations (hearing voices), delusions, negative emotion (fear) and the aches and pains caused by schizophrenia. In addition, their caretakers want elimination of the anger, physical abuse, wandering and inappropriate laughter caused by schizophrenia."

    • "Cognitive ability: Overcoming cognitive impairment: being less confused; being able to remember things and being less forgetful (e.g., with respect to their day to day tasks); being able to concentrate on or pay attention to their work, household tasks or to conversations with other people; and being alert, with a sharp mind."

    • "Activity: Overcoming apathy (a core feature of schizophrenia) by: "not being lazy or sleeping all the time"; following a routine (e.g., waking up/eating on time); exercising and being fit; keeping busy (e.g., pursuing hobbies such as reading or making handicrafts); being engaged in some form of productive tasks (e.g., cooking, cleaning or other housework) and performing these satisfactorily."

    • "Self-care: Taking care of their own health and maintaining good hygiene practices. Examples include taking medicines on their own without being persuaded or reminded to; informing others when feeling unwell; sleeping well and having healthy eating habits (e.g., having a good appetite and eating proper meals); bathing regularly and being clean; taking care of personal and household belongings; not smoking cigarettes or inhaling tobacco; and maintaining a neat and groomed appearance by combing one's hair and dressing appropriately."

    • "Overcoming negative personality traits" (to be less schizoid or paranoid): "Being less socially withdrawn and insensitive; being more self-confident; being less suspicious; not bearing grudges or feeling victimized."

    • "Reduced side-effects: (Antipsychotic medications do differ significantly in their side-effects; hence it is possible to reduce side-effects.)"

    • "Management without medication: (Unfortunately this is not possible because of the high relapse rate off of antipsychotic medication.)"

The above definition of recovery is much more meaningful than the usual outcome measures used in research. Most of the outcome measures used in schizophrenia research (like "20% decrease in the total PANSS score") have little or nothing to do with a patient's quality of life, occupational or social functioning. Yet improvement in quality of life, occupational and social functioning are the outcomes that matter most to patients and their families. The problem with using somewhat meaningless outcome measures (like "proportion of patients remaining in the study") is that this approach gives artificially high placebo response rates.

Placebo response rate

Example Of A Meaningless Outcome Measure

Unfortunately, current treatment of schizophrenia seldom results in full recovery. For first-episode patients with schizophrenia, 32% achieved symptomatic remission at 6-month follow-up, but only 11% achieved functional (occupational and social) remission. For first-episode patients with schizophrenia, on 5-year follow-up, 15.7% were fully recovered. For early-onset schizophrenia (median age 16), on 15-year follow-up, 85% had at least one rehospitalization, 8% were fully recovered, 56% had a moderate outcome, and 36% had a poor outcome.

Schizophrenia is often an episodic disorder characterized by patients going in and out of symptomatic remission. Patients often improve on antipsychotic medication; then stop their antipsychotic medication because they feel "cured". However, in a year or two (or even a few weeks), their psychosis returns which forces them to restart their antipsychotic medication. In a few years, they again feel they are "cured", and again stop their medication - only to have their psychosis return again, and require antipsychotic medication. This cycling on and off antipsychotic medication commonly goes on for decades.

Researchers often make the error of assuming that, because certain patients are off antipsychotic medication and doing well, that these medication-free patients don't need antipsychotic medication. These researchers fail to appreciate that these apparently recovered, unmedicated patients may just be in an interlude between their psychotic episodes. To prove that certain individuals with schizophrenia don't need lifelong antipsychotic medication; researchers would have to prove that some patients fully recover and stay well for years after stopping their antipsychotic medication. Such a long-term followup study of patients off their antipsychotic medication hasn't been done.

The first 5 years after psychotic onset are the worst, and have a high risk for relapse, rehospitalization and suicide. As many as two-thirds of completed suicides in schizophrenia occur within six years of diagnosis. After 5-10 years, schizophrenia tends to reach a plateau of psychopathology, with as many patients tending to improve in the long-term as those who tend to show further deterioration. Several factors have been associated with poor long-term outcomes in schizophrenia: prolonged untreated psychosis, social isolation, illicit drug use, insidious onset, living in industrialized countries, immigration, lack of affective symptoms, non-adherence to medications, the presence of early negative symptoms, and cognitive dysfunction.

Schizophrenia: 10 year follow-up

Schizophrenia Recovery At 10-Year Follow-up

Antipsychotic medication is absolutely essential for the treatment of schizophrenia. Also essential are social support programs (e.g., drop-in centers/clubhouses, sheltered employment, subsidized/supervised housing, free medication, disability pensions). If a patient needs psychiatric hospitalization; antipsychotic medication usually ensures that the patient will be discharged home within a month. Most nations permit patients to be involuntarily hospitalized if they are at risk of harming themselves or others, or if they have serious self-neglect. Some nations have outpatient commital laws which compel potentially dangerous outpatients with schizophrenia to stay on their medication or face immediate involuntary repeat hospitalization.

Why not close all psychiatric hospitals and just treat individuals with schizophrenia in the community? This was actually tried in Italy and Denmark, and it was a disaster. In 1999, Denmark tried to quickly downsize its psychiatric hospitals and this subsequently caused a 100% increase in suicide, and a doubling of the rates of criminal acts committed by psychotic patients. In addition, this "deinstitutionalization" policy caused increases of 80 to 100% in acute hospital admissions for psychotic patients.

Unfortunately, at least 50% of individuals with schizophrenia refuse to stay on their medication. After a few weeks or months off medication; the psychotic phase of schizophrenia usually returns. A minority of patients can go off antipsychotic medication, and not suffer a psychotic relapse. However, even though not psychotic, these medication-free patients usually are significantly impaired due to "residual symptoms" of their untreated schizophrenia. Thus it would be a mistake to consider these patients totally recovered.

Since so many individuals with schizophrenia refuse to take their oral antipsychotic medication, these oral medications are being replaced by long-acting injectable antipsychotic medications that last 2-4 weeks between injections. Once patients have been stabilized on oral antipsychotic medication; they can be switched over to these long-acting injectable antipsychotic drugs. Long-acting injectable medication improves the complance rate (i.e., percentage of patients staying on medication); hence improves treatment benefit.

It has been difficult to compare the effectiveness of different treatments for schizophrenia because there hasn't been a consensus on what constitutes "recovery" in schizophrenia. Recently, the symptoms that are the best indicators of recovery or relapse in schizophrenia have been identified (using the 78-item Internet Mental Health Quality of Life Scale). Recovery in schizophrenia could be defined as the total disappearance of these indicators. Likewise, relapse could be defined as an increase in these indicators.

Good News: Staying On Antipsychotic Medication For Years Really Works

All of the patients with inactive schizophrenia in this study were continuously treated with antipsychotic medication for many years. By faithfully staying on their antipsychotic medication, these patients with inactive schizophreia had a relative absence of psychotic symptoms, cognitive impairments, and schizoid or paranoid behaviors.

This study identified the symptoms that differentiate active (i.e., moderate/severe) schizophrenia from inactive (mild/in remission) schizophrenia (using the Internet Mental Health Quality of Life Scale).
  • Occupational and social symptoms in schizophrenia:
    • #11. Having few or no close friends (active schizophrenia=78%, inactive schizophrenia=38%)
    • #12. Mistrust of people in general (active schizophrenia=45%, inactive schizophrenia=9%)
    • #13. Inability to live independently (active schizophrenia=47%, inactive schizophrenia=15%)
    • #15. No competitive employment (active schizophrenia=81%, inactive schizophrenia=34%)
    • #16. Not doing expected housekeeping (active schizophrenia=47%, inactive schizophrenia=8%)
    • #17. Requiring financial assistance (active schizophrenia=79%, inactive schizophrenia=35%)
    • #25. Fears leaving home without a companion (active schizophrenia=13%, inactive schizophrenia=1%)
    • #51. Poor overall psychosocial functioning (active schizophrenia=79%, inactive schizophrenia=13%)
    • #56. Submissiveness (active schizophrenia=36%, inactive schizophrenia=15%)
    • #58. Intimacy avoidance (active schizophrenia=62%, inactive schizophrenia=19%)
    • #59. Social withdrawal (active schizophrenia=38%, inactive schizophrenia=11%)
    • #60. Lack of emotional expressiveness (active schizophrenia=29%, inactive schizophrenia=12%)
    • #70. Being suspicious of family and friends (active schizophrenia=40%, inactive schizophrenia=10%)
    • #72. Feeling victimized (active schizophrenia=24%, inactive schizophrenia=10%)
    In this study, 71% of all individuals with schizophrenia remained single, and there was no difference in this regard between those with active or inactive schizophrenia. 71% of individuals with active schizophrenia were disabled compared to 27% of those with inactive schizophrenia.

    These findings illustrate just how profoundly schizophrenia impairs an individual's social functioning, and why many individuals with schizophrenia find it so difficult to live independently. Thus there is a real need for community services which assist patients to live independently. For the many patients that can't live independently, there is a major need for psychiatric group homes in which patients can live in the community in a sheltered environment under professional supervision.

    The most outstanding symptom of schizophrenia is unemployment; 81% of individuals with active schizophrenia did not have competitive employment. Even 34% of patients with inactive schizophrenia had no competitive employment. This unemployment is directly the result of the psychotic symptoms and cognitive impairments caused by schizophrenia. Many individuals with active schizophrenia find it very difficult to do even full-time sheltered employment. Patients with schizophrenia need employment, but their employment must be tailored to their level of disability.

    Almost the majority of individuals with active schizophrenia had much/severe difficulty doing their expected housekeeping. 70% of individuals with active schizophrenia were on some form of financial assistance, and 8% lived in poverty. In contrast, housekeeping impairment and need for financial assistance were much less prevalent in individuals with inactive schizophrenia.

    Schizophrenia alters personality, and makes individuals more schizoid. Thus those with active schizophrenia had abnormal submissiveness (36%), intimacy avoidance (62%), social withdrawal (39%), and lack of emotional expression (29%).

    Schizophrenia also makes people more paranoid. Thus those with active schizophrenia felt victimized (24%) and had suspiciousness directed at family and friends (40%).

    These schizoid and paranoid behaviors were uncommon in patients with inactive schizophrenia.
  • Psychotic and cognitive symptoms of schizophrenia:
    • #37. Grandiosity (active schizophrenia=9%, inactive schizophrenia=0%)
    • #38. Delusions or hallucinations (active schizophrenia=63%, inactive schizophrenia=2%)
    • #39. Conceptual disorganization (active schizophrenia=13%, inactive schizophrenia=0%)
    • #40. Distractibility (active schizophrenia=70%, inactive schizophrenia=7%)
    • #41. Apathy (active schizophrenia=69%, inactive schizophrenia=14%)
    • #42. Forgetfulness (active schizophrenia=58%, inactive schizophrenia=9%)
    • #43. Impaired executive functioning (active schizophrenia=65%, inactive schizophrenia=15%)
    • #44. Impaired social communication (active schizophrenia=18%, inactive schizophrenia=0%)
    • #50. Lack of insight (active schizophrenia=34%, inactive schizophrenia=1%)
    The majority (63%) of individuals with active schizophrenia had much/severe difficulty with delusions and hallucinations. The cognitive impairments in active schizophrenia are just as crippling as the psychotic symptoms. 70% of individuals with active schizophrenia had much/severe difficulty with distractibility. That's why many of them reported that they stopped reading because they just couldn't concentrate.

    Severe apathy (with inability to initiate and persist in goal-directed activities) affected 69% of the individuals with active schizophrenia. Neurologically, damage of the basal ganglia can produce apathy. If schizophrenia is not treated with antipsychotic medication, this illness eventually results in some patients becoming mute and motionless. You can see these unfortunate individuals sitting all day, silent and motionless, at bus stops. This tragic condition mirrors exactly the avolitional state known to be associated with severe damage to the prefrontal cortex-basal ganglia circuits of the brain.

    Of those individuals with active schizophrenia; 58% had much/severe difficulty with forgetfulness, 65% had impaired executive functioning (causing impaired planning and problem-solving), 18% had impaired social communication (with their responses limited to very few words), and 34% partially/totally refused help because of their lack of insight.

    These cognitive impairments were uncommon in patients with inactive schizophrenia.

    This study showed that, even in individuals with inactive schizophrenia, there are significant "residual" symptoms of schizophrenia.
  • Residual symptoms of schizophrenia seen in individuals with inactive schizophrenia:
    • #11. Having few or no close friends (inactive schizophrenia=38%)
    • #13. Inability to live independently (inactive schizophrenia=15%)
    • #15. No competitive employment (inactive schizophrenia=34%)
    • #17. Requiring financial assistance (inactive schizophrenia=35%)
    • #41. Apathy (inactive schizophrenia=14%)
    • #43. Impaired executive functioning (inactive schizophrenia=15%)
    • #56. Submissiveness (inactive schizophrenia=15%)
    • #58. Intimacy avoidance (inactive schizophrenia=19%)
    Individuals with inactive schizophrenia may mistakenly be seen as being recovered since they no longer have psychotic symptoms. Yet many of these individuals with inactive schizophrenia are very disabled by their residual symptoms. Thus it would be a serious mistake to call these individuals recovered (as some researchers have done).

    Other research has shown that at least 50% of patients with schizophrenia continue to experience psychotic symptoms more than 10 years after onset. At least 70% of individuals with schizophrenia are not competitively employed, are single, and have a poor level of psychosocial functioning 10 years after first admission.

    One of the core features of schizophrenia is lack of insight; thus it is extremely difficult to convince psychotic individuals lacking insight to stay on their antipsychotic medication. Nearly half of patients drop out prematurely from pharmaceutical research studies. Since every patient who prematurely drops out of a research study is technically a treatment failure, these high attrition rates make it very difficult to prove that treatments are effective.

    After each psychotic relapse, individuals may improve by restarting their antipsychotic medication, but most never totally return to their pre-relapse level of psychosocial and cognitive functioning. Thus it is essential that individuals with schizophrenia stay on their antipsychotic medication for their lifetime.

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    The Problems With Online Schizophrenia Support Groups

      There are now many anti-medical, anti-science online mental health support groups. For example, there are "pro-ana" support groups that promote anorexia nervosa. An anti-medical treatment website, "The Icarus Project", promotes psychosis as being a gift. The "Hearing Voices Network" opposes medical treatment of schizophrenia, and teaches that psychosis (hearing voices) is normal and "a relatively common human experience that needs to be accepted and supported". Even the popular website promotes bogus vitamin treatments for schizophrenia.

      There can be two major problems with online schizophrenia support groups:

      • Websites, or their support group members, may actively oppose the medical treatment of schizophrenia. Yet when psychotic individuals have been repeatedly hospitalized for schizophrenia; treatment with antipsychotic medication is usually the only thing that can keep them out of hospital and living happily at home. Thus those websites or individuals that advise psychotic individuals to not take their antipsychotic medication are giving very harmful advice.

      • Two centuries of psychiatric experience has proven that a delusion is "a persistent false psychotic belief that is maintained despite indisputable evidence to the contrary". The same is true for hallucinations. Simply stated: you can't talk psychotic individuals out of having their delusions or hallucinations. You can brow-beat psychotic individuals, and teach them not to admit to having their delusions or hallucinations - but they still have them. The best you can do verbally is to explain that these delusions and hallucinations are symptoms of their psychosis, and that antipsychotic medication usually will significantly reduce or eradicate these psychotic symptoms. There are many psychological, social, occupational and financial interventions that are helpful in the treatment of schizophrenia, but none of them work unless severely psychotic individuals first have their psychosis controlled with antipsychotic medication.

        You can see proof of this by going to any online schizophrenia support group, and reading the progress of the psychotic group members. You will immediately see that, over the years, the only thing that stopped these member's psychosis was their use of antipsychotic medication. You will also notice that severely psychotic members never follow other member's advice to stay on, or increase, their antipsychotic medication. Once individuals become severely psychotic; their illness always convinces them that they can't trust their psychiatrist, and don't need medication or hospitalization.

        This is the major limiting factor for online schizophrenia support groups. These support groups are only helpful for healthy individuals with schizophrenia. Such healthy individuals greatly benefit from the friendship and sharing of helpful information that occurs in such online groups. However, once individuals become quite ill with their schizophrenia; they will not accept other member's helpful advice. Thus online support groups for severely psychotic individuals are completely ineffective. It can even be very harmful if the website or support group members tell severely psychotic individuals that they should avoid medical treatment.

    Excerpts From An Online Schizophrenia Support Group

    Here is an example of an interaction on an online schizophrenia support group. It illustrates how a severely psychotic member received both very bad, and very good advice from other support group members.

    • Online Support Group Member:
      "the demons wont leave me alone i cant sleep because they are scaring me and they have said they wont go and they wont stop trying to get inside me. they want me to do things i dont know that i can the others in my head are mad at me they are busy as well because of the mess i made and cause i didnt do what they said i tried and i failed. i am scared i cant do this i dont know what to do anymore i am so tired and scared and sad all the time. it is my fault i should have done what the others said. i cant do this. i cannot take medication the others in my head wont let me they say is it going to hurt me. and they can hurt me i am really scared i dont what to do. I don't know who I can trust anymore and I cannot do what they can they have a lot more magic than I do. The others in my head I trust but there are so many of the demons I don't know which is which and some have kind of been trying to trick me so I have to be extra cautious I don't know what to do anymore I can't make it stop. I am trying but I don't think I can fight them anymore they won't leave I have been trying since I was little but they won't go until I do what they ask they said they would give me a break until I was older and they did but now I am older and they want me to do all the stuff for them which is very difficult and exhausting. I can't make this stop I can't do this."

    • An Unhealthy Member Responds:
      "get sea salt and onions, place onions in window cills, salt all around the floors. get green stones place in corners also get a gauss meter for smartphone, find elevated levels, get charcoal mesh screen and polyester and hang over those areas."

    • Another Unhealthy Member Responds:
      "I've had this problem on and off for many years. I read just today though that the most powerful exorcist is the actual victim of the demons. I've found that to be true."

    • Fortunately, A Healthy Member Responds:
      "I've been there. They can't hurt you. Are you on any meds? I've had these same thoughts before. Just keep it in your mind that even though things can get close, they can't really hurt you. It took me 16 years to find the right meds and 13 to find a good therapist. You need someone to talk to about it, and realize you are wide awake in a dream you can't turn off. Fight the demons. Do not fear them. You can do this. ::hugs::"

    • Another Healthy Member Responds:
      Like someone else said, no one on here can diagnose you and you may be schizophrenic, or have bipolar or depression with psychotic features, or schizoaffective. I do highly recommend seeing a psychiatrist. I know it feels like you can handle it or it isn't severe enough to necessitate treatment, but we often don't realize the severity or results of these thoughts when in the midst of them.

      Treatments can be harsh and it takes a lot of time and trial and error with different meds. I can say, I use to think my imagination was just overactive, and my hallucinations started around 7. My current diagnoses is schizoaffective, different Dr's have bounced me into different categories. The first time I realized it wasn't just an active imagination was when I was on meds and the voices and delusions disappeared. I never would have acknowledged the severity of my symptoms or that it could be dangerous for me until I was clear headed.

      I've had multiple hospitalizations and Dr's, and medication combinations. Up until this last hospitalization I never thought I could have a relatively normal life or go through a long period symptom free and with relatively mild side effects, but I can now say I've been symptom free for over a year and it is so amazing. It was a horrible long road to get here and I will probably have to be medicated the rest of my life to stay this way. But I'm so glad I started being honest with my Dr's and went through the horrible trials to get to this.

    Timeline Of Posts By A Schizophrenia Support Group Member With "Demons"

    [07-02-2015] "Um i am not sure what to call this but a while ago i my psychologist said i had to go to the hospital because i was going to hurt myself. Anyway that time i was there i made the mistake of telling the doctors about the voices and how i dont think the world is real and a bunch of other stuff even though one of the people in my head warned me not to i was stupid anyway as the doctors said they wanted to help. Anyway the doctor said i had to stay there because they were worried and that there might be some "psychosis" involved and after that i shut up and lied and didnt tell them if anything was happening and they said they were going to get a court order to force me to have meds which i narrowly missed due to a change of law in my area. Since that time i had not brought up those thoughts with anyone until a week or 2 ago with my psychologist (it had been a few years) and last session he made me take a test thing because he doesnt want to be missing anything with me and now i am worried. I dont want to end up in the hospital again because the doctors there are evil and they want to hurt me anyway i guess what i am asking is, is it likely that they may think i am psychotic because i get how someone might think that but i am not they just dont know the whole story.

    i dont have the voices that often mostly whispering and i am pretty sure they are the spirits but i really dont think i am psychotic.

    i am seeing a psychiatrist as well but i dont talk to him much i dont know if i can trust him.

    I was tested for non psych related issues a while ago and they haven't really changed much since then so I think everyone thinks it is psych related but I don't know I don't really trust doctors in general plus I go to say something and then I freeze also the people in my head don't want me to talk to my psychiatrist because they think he wants to hurt us well they think he will if I tell him certain things which is why I have not mentioned most of this stuff since that hospital visit even the other times I was there after that I just told them I wasn't hearing stuff when they asked and I got to leave a lot faster.

    I get (voices) both ones inside my head and ones outside my head and then sometimes thoughts from inside my head come out of my head and I can hear them outside my head and most of my thoughts I don't feel are mine like I don't think they come from me some of them are the OCD I think but I also think of the OCD as separate to me more like it is an entity and then also from the other people in my head. When I hear the whispering it scares me quite a bit they used to tell me to hurt things but now as soon as i hear them I start trying to do things which make other noises so I can't hear them as much cause I get too scared to move otherwise.

    [07-03-2015] I am already seeing a psychologist and a psychiatrist privately. I dont want to take meds because i think they will hurt me. I am worried that my psychologist/psychiatrist will think i am psychotic when i am not because i dont want them to force me to take meds. Sometimes my voices scare me but they aren't the biggest thing I am dealing with at the moment and most of the time I can ignore them so they don't cause me that much trouble I guess.

    [07-14-2015] I feel like there are demons everywhere and they are following me and it is getting worse I am having panic attacks and crying because I don't want them to come into my bedroom or hurt me and I don't want to talk to my psychologist about it because he and my psychiatrist already think I am psychotic but I don't think so but I didn't know where to put this but does this even sound like psychosis? I really do just think it is the demons though.

    [07-15-2015] For me logically nothing exists nothing is really real so if I say nothing is real then fine neither are demons but if everything else is real then the demons must be too.

    [07-16-2015] I do try and just accept that they are there but I get scared they will hurt me because I think they are powerful and can make bad things happen.

    [07-19-2015] Nighttime is the worst because I feel them EVERYWHERE and see glimpses but I think they try and hide from me but it is hard because now I have a whole bunch of OCD rituals which are connected to this.

    [07-20-2015] Ok firstly I am 99.9% sure that I can tap into my psychic abilities anyway sometimes I want to talk to my psychologist about this stuff but I don't want him to think I am psychotic my psychiatrist already thinks I am at times but this is not anyway should I just keep it to myself or should I tell him?

    [07-21-2015] Psychic abilities: I don't think I will mention it I think there is enough other stuff happening to talk about at the moment.

    [07-26-2015] Psychic abilities: I was only thinking about trying to access them to try and get rid of something but I am worried that if I do I will end up with more problems than I started with I do tell my psychologist some things but it is hard because I never know who I can trust or who is real.

    [08-01-2015] Psychic abilities: It is not all consuming I have given up on it anyway because I think there are bad sprints attached to me and if I tried to do that I think it would let them in further and also let other bad things in so I decided against it for now.

    [07-26-2015] I am at the ignore point at the moment I just keep trying to pretend it isn't there.

    [07-27-2016] I do hear whispers sometimes they are louder than other times. I have been trying for over a year to pretend the demons are not real and it isn't work. i dont think i am a self though or have one i dont know how to explain it i dont know how to become something that doesnt seem to exist.

    [07-28-2015] I don't feel like I exist I think if I even have a me it must be in pieces because I certainly don't feel whole ever I don't know how to explain what I am thinking lately all of my words have been getting mixed up and it is tiring.

    [08-05-20151] It is like they are around every corner hiding waiting to jump out at me. The hospital is a bad place. Because the doctors are evil and they are mean to me whenever I am there also they lie a lot and then lie about lying.

    [08-06-2015] I have one (person who tried to help) but she has done all she can.

    [11-24-2015] Ok I am going to try and word this carefully cause it is a bit well I will just try and say it.

    If you were to say to a mental health professional that you respectfully disagree that you are psychotic would they take you seriously or would they assume you were even more psychotic because you didn't agree with them? Would they give you a chance to explain why you don't agree or would they just ignore you. When this word (psychosis) has come up for me I have never said anything I just sat there but I kind of feel like I would have liked to have said I disagree only I was too scared.

    [11-28-2015] I don't want to be aggressive about it I just don't want them to not know if I am feeling a certain way about something if I did say something i it would be all quiet.

    Ok I really don't know what this is but I sometimes I can't speak like I literally can't get the words out of my mouth or I will stutter or sometimes the words will mix and I get weird half words and also sometimes I stop mid way through a sentence cause I can't remember what I was saying but like this happens often and also another thing is when I am writing sometimes I forget which letters are which and like I will mix things up and I can't read like I can't process the words in my mind like I see them but I can't work out the whole sentence and I am not dyslexic because this has only been. Happening in the last maybe year and a half. Anyway I really don't know what this is so any advice would be great.

    [11-30-2015] I was just looking stuff up and came across something called negative symptoms and wondered if that might be to do with it.

    [03-09-2016] my psychiatrist and psychologist say i am psychotic i do not think it am but do you agree with them?

    i think they are trying to hurt me. this is kind of complicated so sorry if i am explaining it badly. anyway there are "others" in my head that are not me and they put thoughts in my head and show me things and tell me to do things they are magical and they are from another world. they say that (lets call them A and B) A made this world and it is fake and that A was not supposed to make this world and by making this world it was bad to B and disrupted the balance. B and the others in my head are on the same side and they want me to do some things so that i can go back to the real world and bring evidence of what A did to the ones who kind of like govern the real world so that A does not do the bad things again and so that they stop. because A made this world A is controlling my doctors so that they try and stop me from doing what B wants and A is also controlling the people around me so there are always people watching me and if i am not careful they will hurt me. also i think there are demons attached to me which may be A's doing but i am not sure about that but there are demons everywhere and i can feel them and they whisper in my ear sometimes and say bad things they scare me. the demons also come from one of the other worlds well some of them not all of them my doctors do not know all of this they just know there are others in my head and about that there are demons attached to me. my doctors want me to take medication but i cant because the others in my head say it is poison and that they are evil and that they want to hurt me. the others also say that about the people at the hospital. the others tell me to hurt myself and sometimes to hurt other people.

    They put thoughts in my head that are not my thoughts and sometimes they tell me something and will make something happen to show me stuff.

    i really dont know what to do i am tired i wish people could just accept that people are different and that that doesnt mean they need to be taking "medication" or that they are crazy it is perfectly acceptable to believe in demons in other cultures so why cant i without being told i am "sick" all the time i am not just because others dont understand doesnt mean ugh i am so tired of this i am not sick and them saying that just proves my point.

    i think one of my doctors put something in my head which is why i keep having the bad thoughts and why i cant make them stop.

    [03-10-2016] why is it that when people think you are psychotic they treat you like you are incompetent and stupid and like you are weak and they ugh i am so sick or people not treating me like a human being like why do they have to be so patronising. does anyone else get treated badly because of this.

    [03-11-2016] i can't take meds because the others in my head wont let me they say it will hurt me and it is poison

    [05-26-2016] I have decided not to bother trying to explain things to my psychiatrist anymore as there is no point I do not believe my problem is medical and though he does he is just going to have to deal because it isn't. He is not able to understand no one really is other than the others and the ones on that side because "He" won't let anyone understand and I have too much to do I have a lot of the magic stuff to do and they have given me a timeline where certain things have to be done by and I can't fail with this stuff but I don't know how to tell him I will not be going much longer without him doing something how should I word it so that he knows what I am trying to say?

    [05-30-2016] So i am back in hospital again i was tricked into coming here by the staff at the house and didnt get to see either my psychologist or psychiatrist i was super mad at the whole situation so i ended up kicking all the furniture and stuff and then they made me take some lorazepam and now they want to keep me for the night. I am so mad right now.

    [06-07-2016] ok well so i need advice or opinions or both cause i dont know what to do i dont know if i should see my psychiatrist anymore as i am not convinced my problem is medical. my psychiatrist thinks i am psychotic and has said so many times but i do not think i am my psychologist also thinks i am psychotic but that is a separate issue. anyway my psychiatrist says i need to be on medication but the demons and the others in my head say i cant and shouldnt take it because it will get rid of my magical powers and they need me to have those powers to do things for them and some other very important things but they say medications will hurt me and that the doctors want to hurt me.

    do you think i should keep seeing him and do you think i am psychotic like he says?

    i am just magical like i have powers and stuff and i can talk to the demons and the others in my head are angles Satans angels and God sends bad demons to try and hurt me because right now everything is reversed and it is hard to explain but i do not think i am psychotic and i dont know how to explain that to my psychiatrist.

    [06-08-2016] it is not as simple as deciding what I want not that that is even simple like this is the whole universe at stake here if I screw things up. I don't mean to sound dismissive I am just trying to clarify but finding words is hard today.

    [06-14-2016] the demons wont leave me alone i cant sleep because they are scaring me and they have said they wont go and they wont stop trying to get inside me. they want me to do things i dont know that i can the others in my head are mad at me they are busy as well because of the mess i made and cause i didnt do what they said i tried and i failed. i am scared i cant do this i dont know what to do anymore i am so tired and scared and sad all the time. it is my fault i should have done what the others said. i cant do this.

    i cannot take medication the others in my head wont let me they say is it going to hurt me. and they can hurt me i am really scared i dont what to do.

    I don't know who I can trust anymore and I cannot do what they can they have a lot more magic than I do. The others in my head I trust but there are so many of the demons I don't know which is which and some have kind of been trying to trick me so I have to be extra cautious I don't know what to do anymore I can't make it stop.

    I am trying but I don't think I can fight them anymore they won't leave I have been trying since I was little but they won't go until I do what they ask they said they would give me a break until I was older and they did but now I am older and they want me to do all the stuff for them which is very difficult and exhausting. I can't make this stop I can't do this.

    [06-15-2016] i am so tired i have been trying to ignore them but that makes them mad everyone is made at me even the angels well they are more disappointed with me than mad but still it hurts i am tired i still have to do what they want but it is so hard."

    Timeline Of Posts By A Schizophrenia Support Group Member Wanting To Remove A "Computer Chip"

    [08-17-2015] "Yeah so as I've gone on about before I believe there's a chip in my arm. I used to think it was in my head and very well may be there. But now I'm thinking there is no chip, this is delusional and I need to accept the help. I hear voices that tell me there's a chip there but there isn't. There couldn't be, I've even had an mri of my brain showing no chip and xrays of my arms showing no chip. It's bull shite. There's no chip there. After so much believing I can finally say, there is no chip there. End of.

    [08-17-2015] It's kind of hard to let go of something I believed so much for about a year, but I'm over it!

    [08-19-2015] It may seem small but this delusion has been my dominant problem so I think I'm making progress.

    I thought my voices where communicating with me through the chip, because they said they where. Now I'm thinking they're just hallucinations and nothing more. I'm not going to try and fight them anymore, I'm just going to accept that they're there, notice them and let them float away without giving them any emotion whatsoever. Easier said than done, but it's a process!

    [11-03-2015] Where do you mainly hear your voices? Mine are at evening/nightitme but sometimes rarely during the day.

    [11-04-2015] Meds have dulled down my voices quite a bit which I'm fortunate for as I have less periods where I can't handle them. Though over the past month or two this one particular voice has grown incredibly evil and it's really hard to hear him every day.

    [02-15-2016] I'm in a peril. I need this thing out of my head now. I have some tools available to me But I'm not even sure how to go about it. The internet hasn't been very helpful so I'm asking here.

    [02-16-2016] I've been off my depot for two weeks but it should still be in my system so it's not the meds. I don't need meds anymore.

    I'm going to get a magnet (suggested by another member as a way to deactivate the microchip).

    I believe that you guys think there's nothing there. But I know there is, they put it in when I was a teenager.

    I'm going to a&e (hospital) tomorrow to make them take it out

    I really need this thing out, do you think if i go to the ER dept they'll take it out? Or treat me like a crazy person?

    [02-17-2016] Got my depot today. I feel absolutely rotten. Really frustrated that they can't do anything to help me but hoping the meds will help dull it for a while.

    [02-18-2016] How am I supposed to get on with my life if I have to take this feckin depot. What about when I want to have children and I can't come off it. The baby goes into withdrawals? I'm an absolute waste of a human being.

    [02-19-2016] I feel better today. No urges to cut my head open.

    I'm going to do more research to prove I'm not completely mental.

    [02-23-2016] Found some books on amazon about people who have chips illegally implanted in their bodies.

    Also going to go to my pdoc on thursday with an ultimatum, get me and xray or I'm going at it myself.

    I think it's outside of the skull but connected to my brain. If I can get rid of the chip it'll cut off the connections within the brain.

    I'm just after figuring out why this is happening to me. I got overcome by this a week or so after my second year comp sci exams in college. That summer I was planning to begin research for my thesis in quantum computing. I'm a genius and this has been known since I was a child, they implanted the chip when I was a teenager and only activated it when they needed to. I was getting too close, if someone was to make the theoretical a physical working machine and make it open source to everyone they'd lose billions, trillions. Especially someone with my skills. They're doing this to get in the way of my research and interests, to dumb me down and get me branded with a mental illness so I'd never be taken seriously.

    I never got a chance to start my research and by their doing dropped out of college 4 months later. Proof that there's a chip in my head.

    I woke up two days later after a "procedure" in a psychiatric hospital with two black eyes, common occurance when ones skull has been opened. I was 16.

    I hear voices through the chip, they can read my mind. They tell me to do things. They've asked me to join them on occasion. I would like to meet them but they never show up.

    I hear noises all over the house that no one else hears.

    People follow me, I reckon it's them looking at me seeing what I'm up to.

    When I'm in appointments all I hear is "don't talk to him, we'll help you, don't talk to him, he doesn't believe you, we can help you"

    These are real people talking to me through the chip in the back of my head. They are an organisation set up to keep those that can change the world down. DOWN!!!!! Nothing is the same anymore. It's all done through hi tech systems that even I don't understand. But I will. I will educate. I will help others. Straight after I rip this demon from my head.

    [02-26-2016] If you have schizophrenia, then yeah you probably should take medication. But for people like me and the OP who don't have a psychotic disorder but are being pushed onto meds it's fundamentally wrong. They're being shovelled down people's throats based on some dudes subjective opinion. Christ, even I thought for a second I needed them because of the psychiatric propaganda being spouted everywhere I go. They shouldn't be used on the amount of people they're currently being used on.

    [03-01-2016] I felt something under my skin.

    [03-07-2016] I've had some developments, i can now feel a lump where the chip should be meaning i should be able to get it out. I was in town today and bought scalpels in an art shop. So we'll see how we get on.

    Been in touch with a number of other victims to this international experiment being undertaken. I'm hoping they can provide me more insight. The general concensus is to not take the meds so I won't be getting my depot next week and then that's it. I'm staying off it. [03-07-2016] How many of you believe you have an implant of some kind, whether it be for torture or that it's causing your symptoms. (Did an online poll: Do you have an implant? Of 20 members that responded: 50% answered "No", 30% answered "Yes", and 20% said "I used to think I did".)

    [04-03-2016] I'm sorry for being such a hyperactive, psychotic, nutjob! Yes, that's what I have been. Still not quite on the level head but things are getting clearer with this med increase that I can see that I'm an idiot and thoughts shouldn't be let out of my head without the supervision of an adult.

    I may have offended some people, went on a few rants... well... I definitely did that and I apologise to anyone on the receiving end of it.

    I like to make jokes but I'm really not very well at the moment and I'm struggling not to project that outwards in an over the top hilariously silly way.

    If anyone was offended, I do sincerely apologise. I like this place and I've made some great friend here. Thanks guys!

    [05-29-2016] So, I'm not psychotic. Never have been psychotic and have a low chance of becoming psychotic with my history of having never had psychosis.

    So I'm coming off my antipsychotic depot. Due it on Thursday and I've informed them I won't be there. They threatened to discharge me from their services completely, but I'm still seeing a psychologist and after a bit of talking I convinced them to let me keep seeing the psychologist.

    Last time I went off the meds I went a bit loopy. If any of you know me you will probably remember all the posts about Irish nationalism being posted at a consistent rate of 2^64

    I think this was just withdrawals. I've settled down a little bit now. Should start feeling back to normal in two weeks and a slight improvement slowly on from there: get my attention span back, not sleep so much, control my weight gain.

    I think psychology is the way to go to deal with the voices and my concerns about the chip in my head. I've applied through freedom of information for my MRI and am currently looking for a specialist who might look at it for me, the chip is there. I just need a professional who isn't being paid under the table to find it for me. Medication isn't going to 'fix' something that is very real.

    I'm not telling anyone I'm coming off my meds. So if anyone here notices any real changes with me could they tell me? So I know if I'm going through withdrawals and don't realise it. It'd be nice to have a bit of info if I lose insight temporarily while the drug is coming out of my system.

    My doctors said I won't get any withdrawals because the depot slowly goes out of your system over a number of weeks. This is bull, after what happened me the last time.

    When I came off my meds I believed I was in the IRA, I still believe the voices that talk to me are in the IRA but I don't think I am anymore.

    [06-07-2016] I'm seeing a psychologist and I think it's a better way to learn to cope than with meds. He advised against it, but that's all he said about it. He doesn't concern himself with the medication side of things. Only how I am doing.

    [06-11-2016] Just over a week off meds and feeling good. Exam coming up, little bit of stress but nothing major. I'm starting to think this medication was causing my anxiety and coping problems. The voices are controlled by the chip, that's still there.

    [06-16-2016] Yes, some people do have microchips in their heads. I'm not or have never been psychotic so this isn't a delusion. It does bother me having it but I'm making the steps towards getting it removed the right way instead of taking it into my own hands.

    I'm off meds and the voices haven't gotten any worse, they also don't go on about me taking meds any more, they're happy with me. When I get rid of the chip, I get rid of the voices."

    Key Points

    • A healthy support group member gave a very wise description of schizophrenia - it's like "you are wide awake in a dream you can't turn off".

    • Unfortunately, all the other group member's wise advice (not shown) was resisted by both of these psychotic support group members. This reminds us that a delusion is "a persistent false psychotic belief that is maintained despite indisputable evidence to the contrary".

    • The only times when these psychotic group members improved was after their psychiatric hospitalizations (when they were forced to take antipsychotic medication). Once discharged from hospital, they went off their antipsychotic medication and quickly returned to being psychotic.

    • The psychotic group member's posts show that, when their psychotic episode returned, their delusions were virtually word-for-word an exact repeat of their last psychotic episode.

    • The posts (not shown) of the healthy schizophrenia support group members were very friendly and supportive. It was obvious that they greatly benefited from belonging to this support group. However, there is little evidence that posting in the support group had any benefit for these two very ill, psychotic members. In fact, sometimes other psychotic members would reinforce these two members' psychotic beliefs and refusal to seek medical help.

    Schizophrenia Support Group Members Discuss Whether They Consider Themselves "Psychotic"

    Do you think you are psychotic?

    • My psychiatrist and psychologist tell me I am but idk I still think I am just a little bit different but not that I am psychotic. i know i am not "normal" or that i dont believe the same things as everyone else but that doesnt mean that i dont still believe/experience what i do. i just think my reality is different but that it is still real.
    • I recognize that my reality is vastly different than that of other people's, and I recognize that 99% of people think I am psychotic. But I still believe what I do about reality. So I don't really know how "insightful" I'm considered to be.
    • Me too. My family and friends think I'm psychotic, they just don't understand reality the way I do.
    • normal people just don't get it..they see the world their way, I see it quite differently..probably sometimes behave quite differently..and because of that I may be called psychotic..whether or not I'm one I have no idea whether or not I'm psychotic.
    • I've been asking my doctor this for years. I asked the new therapist yesterday and she told me only if I wasn't in reality. I'm not sure what "reality" is, considering my paranoia started at 9. My hallucinations started at 13 and became non stop by 16/17. I've asked so many people and so many doctors but everyone says "I don't know". How am I supposed to know if no one else knows?!
    • My therapist says I am.
    • I asked my boyfriend and he said "at times". I asked when and he said that "I never remember".
    • I never know that I am psychotic until I am no longer "psychotic". As of right now, I feel like I was definitely psychotic all the times I've been in the hospital and I was definitely psychotic when I was hearing voices, but I can say that now because I am not hearing voices because my meds are actualy working!
    • If my voices talk literally 24/7, how am I supposed to know?
    • I've been wanting an answer for years but no one will give me a solid answer.
    • i think its as real as any reality. my paranoia means ive been watched over. my crazy thoughts were a contemplation of the spiritual world. i was simply someone with access to the best of both worlds and it was my job to speak about it.
    • For some reason, not know if or when I am is very irritating
    • I only get psychotic breaks that last 1 full day at most. When im psychotic i dont realize it, but my husband does and he never tells me my ideas are wrong or delusional he just reminds me of real stuff. For example, i was psychotic yesterday and took off all my clothes and started shaking and saying i was trapped and needed to leave, and at that moment i really felt that was reality, but he looked into my eyes and says im safe and everything is okay and he understands how i feel trapped, but for my safety i shouldnt run outside naked, let go to the back porch instead. Thank god i have him.
    • When I'm psychotic I don't know. Later I shudder when I think of it

    Schizophrenia Support Group Members Discuss Their Auditory Hallucinations ("Voices")

    When do you mainly hear your voices?

    • Mine are at evening/nightitme but sometimes rarely during the day. Meds have dulled down my voices quite a bit which I'm fortunate for as I have less periods where I can't handle them. Though over the past month or two this one particular voice has grown incredibly evil and it's really hard to hear him every day.
    • I usually hear mine at night, but it isn't weird for them to happen during the day either, they just don't happen as often.
    • Chronologically, I hear voices in desultory fashion, and at times I hear more than one voice at the same time.
    • Usually at night unless I'm dealing with a lot of stress. In that case they like to join the party.
    • Almost always at night but they also pop in when I'm in a stressful or uncomfortable situation
    • ALL THE TIME, when I am not concentrating hard on something. They guide me, comment on stuff, and are really funny.
    • Right now one is telling me not to tell (He just screamed NOOOOO!) while the other assures him it will all be OK and another one wants me to tell
    • if im not on meds they are pretty much constant. sometimes they come back when i get really emotional or stressed out.
    • In the hospital is when there the worst lately meds arent working so now I'm hearing them day and night
    • Mine start in the morning, stick around through the day, take a break in the evening, then sometimes come back at night.
    • My voices are pretty much consistent throughout the day unless I'm distracted. Depending on how bad I am, it varies as to how much is needed to distract me.
    • Currently watching TV, reading or intently browsing the internet will do the trick but when I was worse, I would still hear the voices over the TV for example.
    • I hear them very often. And they do tend to get louder for me at night and early in the morning. During the day I can distract myself more.
    • I hear them off and on throughout the day
    • *aliens voice* they mostly come at night..........mostly..............and then in the morning. basically any time my headphones are out. he's easier to tolerate as a looming presence than any of his other manifestations.
    • all the time! like he just said that this is dumb and i should kill everyone around me :3 but y'know, whatever
    • I've had voices that are commanding like that. It sucks I'm sorry you deal with that too.
    • the devil talks to me throughout the day trying to encourage me to do very bad things and tries to make me very paranoid about people around me,the other voice; a guy in his late 30s called james tends to be worse at night and some times i hear the devil and james arguing.
    • usually when I'm stressed out or I make a bad grade on a test sometimes they come during night or they're random throughout the day
    • Through the whole day..

    Schizophrenia Support Group Members Discuss Their Memory Loss

    Anyone else have severe memory issues?

    • I'm just curious because my Dr's say it's related to the schizophrenia and also the meds make it worse. I've had the issues get worse and worse as I've aged and the hallucinations intensified. Now I'm medicated and no hallucinations but the memory issues are as bad as ever. I can't remember meeting people even when I've been introduced a few different times. I don't remember books I read, so I gave up most reading, it's useless to read a novel when you cant remember any of the characters or plot the next day. Most movies I can see multiple times and remember little to none of the content, including major character deaths. Today I embarrassed myself again because I went to a work party with my husband and he said, 'This is so and so, he's my boss.' I stuck out my hand and said, "Nice to meet you." He looked at me strange than finally shook my hand and said, "Nice to see you again." This is apparently about my third of fourth time meeting him. I just had this happen at my husband's Christmas party too, with someone even higher up.
    • Yeah my memory isn't what it used to be infact i was talking to my cousin not long ago and he was telling me something that i had apparently done but i have no recollection of it even happening and it was only a few years ago. Also I struggle to remember some parts of my episodes but I'm not sure if that's just my brains way of coping with it all.
    • I have some major memory issues. Sometimes I even forget where I am. I cant remember peoples names, grocery lists, vacations, life events (weddings etc) , whether or not I have eaten all day. My memory is a total mess. . . . . What were we talking about? Lol
    • Yes. My pdoc says part of it is due to the psychotic illness, and some is attributable to the meds. Mine has improved slightly since my psychosis has been less severe, and since we have lowered my doses of risperidone and valproate. My working memory seems to hit my thinking the hardest.
    • Yes my memory is ****. I can't remember the important things let alone the day to day things. The further out from psychosis I am the better my memory is but I'm still missing 3 years of my life. I've lost most of 2013~2014. Unfortunately the bad stuff seems to have stuck with me.
    • Yeah my memory is pretty awful too. I can seem to remember some things but things like faces and names, numbers and lists I can't seem to remember. When I go to the store I usually have a list but I need to be reminded to look at it and even in the rare event that I remember to look at my list I always forget what I read literally like five minutes later.
    • I have a horrid memory, which makes it hard for me to make decisions. I forget a lot of what I read, which is very sad for me because books (and cats) are my life and I've read so many good ones. The only benefit is that I can pick up a book I've already read and because of my bad memory it's like reading it anew.
    • oh god its the worst. its taken me over a year to know most of my coworkers by their faces. not even all. forget anyone i don't have to see every day. any time im out wiht my dad and we run into people i have to fake like i have any idea who they are or how they know me. and i feel the problem with books so much, i always loved to read and now ill forget whats happened by the time i finish a chapter. Im missing huge chunks of 2008-2009 and the last 2 years have just been one huge blur =(
    • Yes my memory is terrible. I typically have to use the quote feature here all the time when responding to non simple questions because I'll forget what I just read. It ****ing sucks.
    • my memory is really bad, i'll be telling people stuff like what my plans are or something and they're like you told me that just a minute ago, i think it's got worse since meds
    • I have lost 95 percent of my 2011-2013 memories
    • Ive had this , still have it , poor with names , but , there's certain kinds of information , I take in easily. Like Computer stuff , however My memory has improved in that 2 years though.
    • I can't even remember what happened the next day... That's bad. I can barely even remember what happened today...
    • I can't remember how many times I've been in the middle of an explanation and then *POOF* completely forget the point I was trying to make. Endlessly embarrassing.
    • I'm borderline face-blind. I can't remember where places are and I never remember what car people drive.
    • When your still having delusions and hallucinations it really made me stress, especially after going under a psychosis for an entire year. My memory was shot, and (getting) my degree was very difficult.

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    Review Articles On The Effectiveness Of Treatment

  • 2013 Research Review Articles
    • Physical Therapies
    • Pharmaceutical Therapies
      • The nature of relapse in schizophrenia (Relapse rates are very high when treatment is discontinued, even after a single psychotic episode; a longer treatment period prior to discontinuation does not reduce the risk of relapse; many patients relapse soon after treatment reduction and discontinuation; transition from remission to relapse may be abrupt and with few or no early warning signs; once illness recurrence occurs symptoms rapidly return to levels similar to the initial psychotic episode; while most patients respond promptly to re-introduction of antipsychotic treatment after relapse, the response time is variable and notably, treatment failure appears to emerge in about 1 in 6 patients.)
          Editor's Comment: This superb review is published online free. It is a must read.
      • The association between schizophrenia and violent or homicidal behavior: the prevention and treatment of violent behavior in these patients (The risk of homicidal behaviours is higher in patients with schizophrenia compared to the overall population. The following factors increase the risk of violence in schizophrenia: young age, alcoholism, substance abuse, noncompliance with treatment, fulfillment of the criteria for antisocial personality disorder and paranoid subtype, history of suicidal ideation and attempts and history of frequent hospitalization. There are many trials showing the efficacy of clozapine on violent and aggressive behavior.)
      • Treatment of adolescents with early-onset schizophrenia spectrum disorders: in search of a rational, evidence-informed approach (Antipsychotics are efficacious in the treatment of early onset schizophrenia (except for ziprasidone). Clozapine is reserved for those with treatment-refractory early onset schizophrenia.)
      • Detection of metabolic syndrome in schizophrenia and implications for antipsychotic therapy : is there a role for folate? (the presence of metabolic syndrome is associated with significant cardiovascular mortality and represents a growing public health concern in the USA. Patients with schizophrenia have a three times greater risk of death than the general population, with cardiovascular disease being the most common cause of this mortality. Use of atypical antipsychotics (AAPs) to treat schizophrenia contributes significantly to this cardiovascular risk.)
      • Clozapine: key discussion points for prescribers (Clozapine is the most effective antipsychotic medication for treatment-refractory schizophrenia and is also approved for suicidality in schizophrenia patients. However, it can cause significant medical morbidity and requires intensive medical monitoring once prescribed.)
      • Schizophrenia past clozapine: what works? (In patients who discontinue clozapine, considering a trial of olanzapine would be worthwhile)
      • Asenapine, iloperidone and lurasidone: critical appraisal of the most recently approved pharmacotherapies for schizophrenia in adults (All three agents are similar in terms of overall efficacy and low propensity for clinically significant weight gain or adverse changes in glycemic or lipid profile. For each drug, comparative and real-world effectiveness studies are lacking, as are effectiveness and safety data in elderly, young and pregnant/nursing patients.)
      • Lurasidone: in the treatment of schizophrenia (In two placebo-controlled, phase II trials, lurasidone 40-120 mg/day was efficacious in reducing the acute symptoms of schizophrenia. In a third phase II trial, the lurasidone groups and haloperidol control group failed to separate from placebo on key endpoints. In two placebo- and active treatment-controlled, phase III trials, lurasidone at dosages of 40-160 mg/day, olanzapine 15 mg/day and quetiapine extended-release (XR) 600 mg/day were efficacious in reducing the symptoms of schizophrenia. In a 12-month, double-blind extension trial, the relapse rate in lurasidone recipients was noninferior to that in quetiapine XR recipients. In a third phase III trial, lurasidone 80 mg/day, but not 40 or 120 mg/day, was more efficacious than placebo for the primary endpoint. In an unpublished trial, there were no significant differences between lurasidone, active comparator and placebo groups on the primary endpoint. Lurasidone was generally well tolerated over the short and longer term. Extrapyramidal symptoms and akathisia occurred in 10-13 % of patients. Lurasidone was associated with a low risk of QT interval prolongation, weight gain, metabolic disturbances and hyperprolactinaemia. [Editor: In 3 out of these 8 trials, lurasidone was no better than placebo])
      • Efficacy of olanzapine in comparison with clozapine for treatment-resistant schizophrenia: evidence from a systematic review and meta-analyses (clozapine is significantly more efficacious than olanzapine for treatment-resistant schizophrenia)
      • A review of paliperidone palmitate (Risperidone long-acting injection (RLAI) was the first second-generation antipsychotic available as a long-acting injection. Paliperidone is the active metabolite of risperidone, is available either as an extended release oral formulation (Invega) or long-acting injection (Invega Sustenna) which is administered monthly by intramuscular injection (deltoid or gluteal). Doses of PLAI can be expressed either in milligram equivalents (mg eq) of paliperidone palmitate or in milligrams of the active fraction of paliperidone. The recommended initiation regimen of 150 mg eq (234 mg) on day 1 and 100 mg eq (156 mg) on day 8 (both administered in the deltoid) achieves therapeutic blood levels rapidly and without the necessity of oral supplementation. No refrigeration or reconstitution prior to administration is required. PLAI has been shown in to be effective in controlling the acute symptoms of schizophrenia as well as delaying time to relapse. Safety and tolerability are comparable to RLAI with no new safety signals. Thus, PLAI may represent the rational development of RLAI with greater ease of use.)
      • Assessing the prospect of donepezil in improving cognitive impairment in patients with schizophrenia (Even though cognitive impairment is manifested in almost all patients with schizophrenia, the Clinical Antipsychotic Trials for Intervention Effectiveness (CATIE) study showed no significant difference between first- and second-generation psychotropic drugs in improving cognitive abilities. Donepezil is not recommended as an adjunct to antipsychotic medication targeting cognitive deficits in schizophrenia subjects.)
      • Efficacy and safety of second-generation long-acting injections in schizophrenia: a meta-analysis of randomized-controlled trials (The present meta-analysis shows superior efficacy for the second-generation long-acting injections over placebo on psychotic symptoms, although with a relatively small effect size; no evidence of superiority in efficacy over oral antipsychotics; and modest evidence of greater symptoms of extrapyramidal side effects.)
      • Interventions to reduce antipsychotic polypharmacy: a systematic review (Antipsychotic polypharmacy remains controversial but is common. Careful switching from polypharmacy to monotherapy seems feasible in a majority of patients with schizophrenia. Directly cautioning physicians not to use polypharmacy is more effective than a less assertive educational approach.)
      • Blonanserin for schizophrenia: systematic review and meta-analysis of double-blind, randomized, controlled trials (Safe and effective antipsychotic medication, but has a 1.62 higher risk of akathisia than risperidone)
    • Psychological Therapies
    • Miscellaneous
      • Meta-guidelines for the management of patients with schizophrenia (A "guideline of guidelines" for the treatment of schizophrenia which not only reconcile the various existing standards but also update them to include the use of several newer agents, most of which were marketed following the publication of existing standards)
      • Improving treatment adherence in your patients with schizophrenia: the STAY initiative (Six principles to improve Treatment Adherence in Your patients are: (1) recognizing that most patients with schizophrenia are at risk of partial/non-adherence at some time during the course of their illness; (2) the benefits of a good therapeutic alliance for identifying potential adherence issues; (3) tailored treatment plans to meet an individual's needs, including the most suitable route of delivery of antipsychotic medication; (4) involving family/key persons in care and psychoeducation of the patient, assuming the patient agrees to this; (5) ensuring optimal effectiveness of care; and (6) ensuring continuity in the care of patients with schizophrenia.)
      • Five-year clinical course and outcome of schizophrenia in Ethiopia (Patients with schizophrenia (n=321) were identified systematically after screening 68378 adults, ages 15-49 years, in rural Ethiopia. The majority (74.9%) had chronic illness at entry and were treatment naive (89.6%). During 5-year follow-up, 96% had received treatment at least once although only about 6% had received antipsychotic treatments continuously. Forty five percent of participants were continuously symptomatic with 30.3% having had continuous psychotic episode. About 20% had experienced continuous remission. Treatment has been a consistent predictor of a favorable outcome.)
      • Remission in schizophrenia: critical and systematic review (In 2005, the Remission in Schizophrenia Working Group published consensus criteria to define remission. Remission has a reported rate of 17% to 78% (weighted mean = 35.6%) in first-episode schizophrenia and 16% to 62% (weighted mean = 37%) in multiple-episode patients, with no statistical difference between the two weighted means (p = .79). Patients who were treated with long-acting injectable risperidone showed high maintenance of remission status. Studies comparing second-generation antipsychotics versus haloperidol showed higher remission rates for the former. The variables most frequently associated with remission were better premorbid function, milder symptoms at baseline (especially negative symptoms), early response to treatment, and shorter duration of untreated psychosis. Rates of symptomatic remission exceeded reported rates for functional recovery. )
  • 2012 Research Review Articles
    • Biological Factors
    • Physical Therapies
    • Pharmaceutical Therapies
      • Risk factors for relapse following treatment for first episode psychosis: a systematic review and meta-analysis of longitudinal studies. (Relapse of positive symptoms was 28% (range=12-47%), 43% (35-54%), 54% (40-63%) at 1, 1.5-2, and 3 years follow-up, in that order. Medication non-adherence, persistent substance use disorder, carers' critical comments (but not overall expressed emotion) and poorer premorbid adjustment, increased the risk for relapse 4-fold, 3-fold, 2.3-fold and 2.2-fold, respectively.)
      • Predicting relapse after a first episode of non-affective psychosis: a three-year follow-up study. (The relapse rates at 1 year and 2 years were 20.7% and 40.7%, respectively. Adherence to medication was the only significant predictor of relapse after a three-year follow-up [hazard ratio (HR) 4.8, 95% confidence interval (CI) 2.9-7.7; p < 0.001]. Comparison of the mean time of relapse between adherent and non-adherent patients also revealed statistically significant differences (933 and 568 days, respectively). 50% of patients will relapse despite being categorized as treatment adherents.)
      • Flupenthixol versus placebo for schizophrenia (We were surprised that this well-established drug had so few data from trials investigating its absolute effects. We think this is unlikely to be rectified some 50 years after its launch and know that this would not happen today. However, even though data are very limited, flupenthixol may well be worthy of careful investigation - partly to ensure that this inexpensive active drug is not forgotten.)
      • Bromperidol decanoate (depot) for schizophrenia (Minimal poorly reported trial data suggests that bromperidol decanoate may be better than placebo injection but less valuable than fluphenazine or haloperidol decanoate)
      • Managing the prodrome of schizophrenia (All evidence taken together makes it difficult to justify specific interventions at the prodromal stage of schizophrenia from the perspective of preventing or delaying the onset of the disorder)
      • Antipsychotic treatment response in schizophrenia (Early nonresponse to antipsychotic treatment may predict subsequent non-response, though early response is not necessarily indicative of future response. If patients do not respond to treatment within the first two weeks of an acute exacerbation, clinicians should consider switching antipsychotic agents, except in patients with first-episode psychosis, for whom a longer trial of the initially prescribed therapy appears to be appropriate.)
      • Information and communication technology in patient education and support for people with schizophrenia (Information and communication technology (ICT) is increasingly being used to deliver information, treatment or both for people with severe mental disorders. Using ICT to deliver psychoeducational interventions has no clear effects compared with standard care, other methods of delivering psychoeducation and support, or both.)
      • Treatment of schizophrenia in pregnancy and postpartum (50-60% of women with schizophrenia will become pregnant; fifty percent of these pregnancies will be unplanned or unwanted. The majority of antipsychotic medications used to treat schizophrenia appear to be relatively safe for use during pregnancy and breastfeeding. There appears to be greater risk for the mother and the fetus/infant in not treating schizophrenia during pregnancy and postpartum.)
      • Anticholinergic effects of oral antipsychotic drugs of typicals versus atypicals over medium- and long-term: systematic review and meta-analysis (Over the medium- and long-term there were no statistically significant differences between the typicals and atypicals in the main anticholinergic side-effects with one exception. We found that in the long-term, the typical antipsychotics were associated with a significantly higher prevalence of blurred vision.)
      • Clozapine: balancing safety with superior antipsychotic efficacy (The primary indications for clozapine are: 1) treatment-resistant schizophrenia or schizoaffective disorder, defined as persistent moderate to severe delusions or hallucinations despite two or more clinical trials with other antipsychotic drugs; and, 2) patients with schizophrenia or schizoaffective disorder who are at high risk for suicide. Concerns over a number of safety considerations are responsible for much of the underutilization of clozapine: 1) agranulocytosis; 2) metabolic side effects; and, 3) myocarditis. These side effects can be detected, prevented, minimized and treated, but there will be a very small number of fatalities. Nevertheless, clozapine has been found in two large epidemiologic studies to have the lowest mortality of any antipsychotic drug, mainly due to its very large effect to reduce the risk for suicide.)
      • Optimizing outcome with antipsychotic treatment in first-episode schizophrenia: balancing efficacy and side effects ( For best clinical long-term outcomes: 1) start with a well-tolerated first-generation antipsychotic medication (thereby avoiding weight gain, insulin resistance, and prolactin-induced changes in gender-specific physiology); then, 2) switch to clozapine if patients are nonresponsive to a trial of 2 first-generation antipsychotic medications.)
      • Drug safety and efficacy evaluation of sertindole for schizophrenia (Sertindole is generally well tolerated, but is associated with a dose-related QTc interval prolongation (+22 ms). Sertindole can be an important second-line option for the treatment of schizophrenia for patients intolerant to at least one other antipsychotic.)
      • Body weight and metabolic adverse effects of asenapine, iloperidone, lurasidone and paliperidone in the treatment of schizophrenia and bipolar disorder: a systematic review and exploratory meta-analysis (Preliminary data suggest the lowest weight gain potential with lurasidone and potentially relevant short-term metabolic effects for asenapine and iloperidone)
      • Antipsychotics in adults with schizophrenia: comparative effectiveness of first-generation versus second-generation medications: a systematic review and meta-analysis (Clear benefits of FGAs versus SGAs for treating schizophrenia remain inconclusive)
      • Clozapine for the treatment of schizophrenia (Clozapine is the treatment of choice for schizophrenic patients who are refractory to treatment, display violent behaviors, or who are at high risk of suicide. However, it is also the antipsychotic with the worst side effect profile, the highest risk of complications, and the most difficult to prescribe.)
      • Paliperidone palmitate for schizophrenia (When flexibly dosed with a mean doses of approximately 70 to 110 mg every four weeks, paliperidone palmitate appears comparable in efficacy and tolerability to risperidone long-acting injection flexibly dosed with mean doses of approximately 35 mg every two weeks)
      • Exploratory analyses of efficacy data from schizophrenia trials in support of new drug applications submitted to the US Food and Drug Administration (A high and increasing placebo response and a declining treatment effect are of great concern in schizophrenia trials conducted in North America.)
      • Comparative effectiveness of atypical antipsychotics in schizophrenia: what have real-world trials taught us? (The CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness), CUtLASS (Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study) and SOHO (Schizophrenia Outpatient Health Outcomes) programmes confirmed the superiority of clozapine over other antipsychotics; CATIE and SOHO also confirmed olanzapine as probably the second most effective antipsychotic. Effectiveness studies have confirmed the high incidence of adverse metabolic effects with clozapine, olanzapine and (with less certainty) quetiapine.)
      • Overdose of atypical antipsychotics: clinical presentation, mechanisms of toxicity and management (Patients with significant CNS depression with associated loss of airway reflexes and respiratory failure need advanced airway management. Hypotension should be treated first with intravenous fluids, with the use of direct acting vasopressors reserved for persistent hypotension. Benzodiazepines should be used for seizures, with barbiturates used for refractory seizures. Intravenous magnesium can be administered for patients with a corrected QT interval exceeding 500 milliseconds.)
      • Anticholinergics in the era of atypical antipsychotics: short-term or long-term treatment? (Some studies suggest improvement in tardive dyskinesia with cessation of anticholinergics. Four studies examined the effects of anticholinergic agent discontinuation on cognition and all observed an improvement post-discontinuation. Changes in symptoms of schizophrenia with anticholinergic discontinuation are conflicting, with more recent studies suggesting an improvement. Given their questionable benefit with continued use, clinicians should consider a gradual withdrawal of anticholinergic agents in stable patients receiving antipsychotics.)
      • Maintenance treatment with antipsychotic drugs for schizophrenia (The review currently includes 65 randomised controlled trials (RCT(s)) and 6493 participants comparing antipsychotic medication with placebo. Antipsychotic drugs were significantly more effective than placebo in preventing relapse at seven to 12 months (primary outcome; drug 27%, placebo 64%, number needed to treat for an additional beneficial outcome (NNTB 3 CI 2 to 3) ...Hospitalisation was also reduced, however, the baseline risk was lower (drug 10%, placebo 26%, NNT 5 CI 4 to 9). .. More participants in the placebo group than in the antipsychotic drug group left the studies early due to any reason (at 7-12 months: drug 38%, placebo 66%, NNTB 4 CI 3 to 5) and due to inefficacy of treatment (at 7-12 months: drug 20%, placebo 50%, NNTB 3 CI 2 to 4). Quality of life was better in drug-treated participants (SMD -0.62). Conversely, antipsychotic medication as a group and irrespective of duration, were associated with more participants experiencing movement disorders (e.g. at least one movement disorder: drug 16%, placebo 9%,NNTH 25 CI 13 to 100), sedation (drug 13%, placebo 9%, (NNTH) not significant) and weight gain (drug 10%, placebo 6%, NNTH 20)... The results clearly demonstrate the superiority of antipsychotic drugs compared to placebo in preventing relapse. )
      • Atypical antipsychotic drugs, schizophrenia, and metabolic syndrome in non-Euro-American societies (The metabolic syndrome development profile in patients with schizophrenia receiving atypical antipsychotic drugs in non-Euro-American societies seems to be comparable to that in European and North American societies)
      • Pharmacological treatment of schizophrenia: a critical review of the pharmacology and clinical effects of current and future therapeutic agents (The D(2) receptor has been the target for the development of antipsychotic drugs. The relative success of antipsychotics in treating positive symptoms is limited by the fact that a substantial number of patients are refractory to current medications and by their lack of efficacy for negative and cognitive symptoms, which often determine the level of functional impairment. In addition, while the newer antipsychotics produce fewer motor side effects, safety and tolerability concerns about weight gain and endocrinopathies have emerged.)
      • Zuclopenthixol acetate for acute schizophrenia and similar serious mental illnesses (This review did not find any suggestion that zuclopenthixol acetate is more or less effective in controlling aggressive acute psychosis, or in preventing adverse effects than intramuscular haloperidol, and neither seemed to have a rapid onset of action.)
      • Asenapine: a clinical review of a second-generation antipsychotic (Is safe and effective. Its most common side effects are: somnolence (13%-24%), extrapyramidal symptoms (EPS) (7%-12%), and dizziness (11%).)
      • Antipsychotics in pediatric and adolescent patients: a review of comparative safety data (Quetiapine and ziprasidone display a better tolerability profile than risperidone and olanzapine in terms of weight gain, glucose metabolism, increases in prolactin levels, and EPS, while aripiprazole seems to be the most weight-neutral.)
      • The treatment of hallucinations in schizophrenia spectrum disorders (The first treatment option for hallucinations in schizophrenia is antipsychotic medication, which can induce a rapid decrease in severity. Only 8% of first-episode patients still experience mild to moderate hallucinations after continuing medication for 1 year. Olanzapine, amisulpride, ziprasidone, and quetiapine are equally effective against hallucinations, but haloperidol may be slightly inferior. If the drug of first choice provides inadequate improvement, it is probably best to switch medication after 2-4 weeks of treatment. Clozapine is the drug of choice for patients who are resistant to 2 antipsychotic agents. For relapse prevention, medication should be continued in the same dose. Depot medication should be considered for all patients because nonadherence is high. Transcranial magnetic stimulation (TMS) currently has the status of a potentially useful treatment method for auditory hallucinations, but only in combination with state of the art antipsychotic treatment. Electroconvulsive therapy (ECT) is considered a last resort for treatment-resistant psychosis. Although several studies showed clinical improvement, a specific reduction in hallucination severity has never been demonstrated.)
      • Lurasidone for schizophrenia: what's different? (Lurasidone is associated with minimal weight gain and no clinically meaningful alterations in glucose, lipids, or the ECG QT interval. As per the product label, the recommended starting dose is 40 mg/day and the maximum recommended dose is 80 mg/day. Higher doses do not appear to be more efficacious, and may be associated with increases in adverse effects, such as somnolence and akathisia. It is recommended that lurasidone be administered once daily with at least 350 calories of food.)
      • A systematic review of the evidence of clozapine's anti-aggressive effects (Clozapine can reduce violence and persistent aggression in patients with schizophrenia and other psychiatric disorders. It may offer an advantage over other antipsychotics, although perhaps exclusively in the case of traditionally defined 'treatment resistance')
      • Practical guidelines on the use of paliperidone palmitate in schizophrenia (Paliperidone palmitate is useful in both the acute and maintenance phases of treatment. Paliperidone palmitate offers some advantages in terms of tolerability, simplicity of treatment initiation and long duration between injections.)
      • Aripiprazole: a review of its use in the management of schizophrenia in adults (Aripiprazole has a lower incidence of extrapyramidal symptoms than haloperidol and fewer weight-gain issues than olanzapine. Aripiprazole also showed a favourable cardiovascular tolerability profile and its use was associated with a reduced risk of metabolic syndrome than placebo or olanzapine.)
      • Treating impaired cognition in schizophrenia (Although current antipsychotic drugs treat psychosis in schizophrenia rather well, their impact on cognitive dysfunction is minimal)
      • Asenapine: a synthesis of efficacy data in bipolar mania and schizophrenia (Asenapine is taken sublingually and is associated with sedation and/or somnolence; it has a lower propensity to weight gain and metabolic disruption than olanzapine. Extrapyramidal side effects (EPS) are associated with asenapine and may be dose-dependent. Asenapine is not associated with sustained hyperprolactinemia or cardiovascular toxicity. Dysgeusia and oral hypoesthesia/paresthesia is associated with asenapine)
      • Antipsychotic treatment for schizophrenia in the maintenance phase: a systematic review of the guidelines and algorithms (Fourteen guidelines and algorithms were identified...Ten of 11 guidelines and algorithms did not recommend discontinuation of antipsychotics within five years; six of them partially recommended antipsychotic discontinuation for patients with first-episode schizophrenia exclusive. All nine guidelines and algorithms that referred to intermittent or targeted antipsychotic strategy endorsed against this strategy. Although being a hot topic of controversy, dose reduction of antipsychotics or lower dose therapy in the maintenance phase compared to the acute dosage is not recommended on the whole concerning atypical antipsychotics, whereas dose reduction appears sometimes considered acceptable for typical antipsychotics.)
      • Clinical pharmacology of paliperidone palmitate a parenteral long-acting formulation for the treatment of schizophrenia (Paliperidone palmitate is a long-acting intramuscular atypical antipsychotic drug indicated for the acute maintenance treatment of schizophrenia in adults. Its mechanism of action, like all other atypical agents, is attributed to the antagonism of brain dopamine D2 and serotonin 5-HT2A receptors.)
      • Clozapine resistance: augmentation strategies (There is scarce evidence of efficacy and safety as regards adjunctive strategies for clozapine-resistant patients)
      • A systematic review of meta-analyses of the efficacy of oral atypical antipsychotics for the treatment of adult patients with schizophrenia (Clozapine had superior efficacy over typical antipsychotics, trailed behind by olanzapine and risperidone. Meta-analyses generally do not support efficacy differences between the other atypical antipsychotics compared with the older typical agents.)
      • Interventions to improve adherence to antipsychotic medication in patients with schizophrenia--a review of the past decade (Interventions that offered more sessions during a longer period of time, and especially those with a continuous focus on adherence, seem most likely to be successful, as well as pragmatic interventions that focus on attention and memory problems. The positive effects of adapted forms of Motivational Interviewing found in earlier studies, such as compliance therapy, have not been confirmed.)
      • Descriptive analyses of the aripiprazole arm in the risperidone long-acting injectable versus quetiapine relapse prevention trial (ConstaTRE) (Clinically stable adults with schizophrenia or schizoaffective disorder previously treated with oral risperidone, olanzapine, or an oral conventional antipsychotic were randomized to risperidone long-acting injectable (RLAI) or aripiprazole and monitored for up to 24 months. Relapse occurred in 27.3% of aripiprazole-treated and 16.5% of RLAI-treated patients. Remission was achieved by 34.1% of aripiprazole and 51.1% of RLAI patients. Clinical global impression-change was improved ("minimally improved" to "very much improved") in 26.4% with RLAI and 15.9% with aripiprazole patients.)
    • Psychological Therapies
    • Other Therapies
    • Miscellaneous
      • Outcomes that matter: A qualitative study with persons with schizophrenia and their primary caregivers in India (32 persons with schizophrenia and 38 primary caregivers were asked what benefits they expected from treatment. Eleven outcomes were desired by both groups: symptom control; employment/education; social functioning; activity; fulfilment of duties and responsibilities; independent functioning; cognitive ability; management without medication; reduced side-effects; self-care; and self-determination. Social functioning, employment/education and activity were the most important outcomes for both groups; symptom control and cognitive ability were more important to persons with schizophrenia while independent functioning and fulfilment of duties were more important to caregivers.)
      • Long-Term Follow-Up of the TIPS Early Detection in Psychosis Study: Effects on 10-Year Outcome (Early detection of first-episode psychosis appears to increase the chances of milder deficits and superior functioning)
      • Clinical instruments to evaluate and guide treatment in schizophrenia (For many treatment studies it is unrealistic to expect a change in actual functioning. Most treatment trials are too brief to permit subjects to change their level of vocational or social functioning. In addition, real-world functioning is influenced by factors such as an individual's financial status or the availability of community services. This has led to the use of functional capacity measures which monitor an individual's ability to perform functionally meaningful tasks even if they do not complete these tasks. Attention has also focused on interview-based measures of cognition and negative symptoms. Both of these psychopathological domains are related to functioning and both are the focus of drug development.)
      • Is early intervention for psychosis feasible and effective? (Excellent review of the research basis for early intervention for psychosis)
      • Clinical interventions for women with schizophrenia: pregnancy (During pregnancy, adjust antipsychotic dose to clinical status, link the patient with prenatal care services, and help her prepare for childbirth. There are pros and cons to breastfeeding while on medication, and these need thorough discussion. During the postpartum period, mental health home visits should be provided. Parenting support is critical.)
      • Overview of violence to self and others during the first episode of psychosis (A substantial proportion of psychotic patients examined after violent suicide attempts (49%), major self-mutilation (54%), homicide (39%), and assault resulting in serious injury (38%) are in their first episode of psychosis)
      • Maternal schizophrenia: psychosocial treatment for mothers and their children (Women with schizophrenia are at risk for not engaging in treatment due to fears of barriers and losing their children. Minimal outpatient psychosocial treatments are available to this population.)
      • Placebo-related effects in clinical trials in schizophrenia: what is driving this phenomenon and what can be done to minimize it? (In recent years there has been a trend towards increasing placebo effects in clinical trials. This has been associated with diminishing drug-placebo differences in clinical trials, which, in turn, has interfered with signal detection for new therapies. Consequences of this increasing placebo effect are increased costs for drug development, more inconclusive and failed trials, delays in the development of new antipsychotics or even the abandonment of the search for new therapies because the risks and costs are seen as too great. There may also be a reduction in the perceived value of newer therapies as poor signal detection is sometimes inappropriately interpreted as newer therapies being less potent relative to older therapies or that treatments are losing their effects over time. More recent trials had an approximate 1.6-fold greater risk for placebo effects. This increase in placebo effect has been greater in trials performed in the US. [Editor: Excellent review of why the placebo effect is rising due to poor experimental methodology])
  • 2011 Research Review Articles
    • Biological Factors
      • Correlations between ventricular enlargement and gray and white matter volumes of cortex, thalamus, striatum, and internal capsule in schizophrenia (Patients with schizophrenia had increased ventricular size associated with decreased cortical gray matter volumes widely across the brain, but not directly correlated with volume loss in the immediately adjacent caudate, putamen, or internal capsule)
      • Schizophrenia as a disorder of too little dopamine: implications for symptoms and treatment (Antipsychotics represent the first effective therapy for schizophrenia, with their benefits linked to dopamine D2 blockade. Schizophrenia was soon identified as a hyperdopaminergic disorder, and antipsychotics proved to be reasonably effective in controlling positive symptoms. However, over the years, schizophrenia has been reconceptualized more broadly, now defined as a heterogeneous disorder with multiple symptom domains. Negative and cognitive features, not particularly responsive to antipsychotic therapy, have taken on increased importance--current thinking suggests that these domains predate the onset of positive symptoms and are more closely tied to functional outcome. That they are better understood in the context of decreased dopamine activity suggests that schizophrenia may fundamentally represent a hypodopaminergic disorder.)
      • Subjective well-being in schizophrenia as measured with the Subjective Well-Being under Neuroleptic Treatment scale: a review (Striatal dopamine D(2) receptor occupancy is correlated with subjective well-being. Early positive response of subjective well-being is predictive of a better outcome.)
      • Maternal infection and schizophrenia: implications for prevention (Accumulating evidence suggests that maternal infection is a risk factor for schizophrenia. Prospective epidemiological studies indicate that maternal influenza, toxoplasmosis, and genital/reproductive infection are associated with this disorder in offspring. Previous studies suggest that treatment or prophylactic efforts targeting these and other infections could have significant effects on reducing the incidence of schizophrenia, given that they are common in the population and the effect sizes derived from epidemiological studies of these and other microbial pathogens and schizophrenia, to date, are not small.)
    • Physical Therapies
    • Pharmaceutical Therapies
      • Preventing the second episode: a systematic review and meta-analysis of psychosocial and pharmacological trials in first-episode psychosis ("The analysis of 3 RCTs of psychosocial interventions comparing specialist First Episode Psychosis (FEP) programs vs treatment as usual involving 679 patients demonstrated the former to be more effective in preventing relapse (odds ratio [OR]=1.80, 95% confidence interval [CI]=1.31-2.48; P<.001; number needed to treat [NNT]=10). While the analysis of 3 different cognitive-behavioral studies not specifically intended at preventing relapse showed no further benefits compared with specialist FEP programs (OR=1.95, 95% CI=0.76-5.00; P=.17), the combination of specific individual and family intervention targeted at relapse prevention may further improve upon these outcomes (OR=4.88, 95% CI=0.97-24.60; P=.06). Exploratory analysis involving 1055 FEP patients revealed that relapse rates were significantly lower with second-generation antipsychotics (SGAs) compared with FGAs (OR=1.47, 95% CI=1.07-2.01; P<.02; [NNT]=10).")
          Editor's Comment: A number needed to treat greater than 8 is generally accepted as not being clinically significant. Thus this review's conclusion that second-generation antipsychotics were superior to first-generation antipsychotics is highly suspect.
      • Lurasidone: a clinical overview (The recommended dose is 40-80 mg given once daily, with no titration needed. Lurasidone should be taken with food. The tolerability profile of lurasidone is noteworthy in terms of a good weight and metabolic profile and no cardiovascular adverse effects such as orthostatic hypotension or prolongation of the QTc interval. )
      • Iloperidone: a clinical overview (The target dose of 6 mg bid can be achieved in 4 days, with titration recommended to minimize postural hypotension. The maximum recommended dose is 12 mg bid. The tolerability profile of iloperidone is noteworthy in terms of modest weight gain, no medically important changes in lipid and glucose levels, little in the way of prolactin elevation, and absence of extrapyramidal side effects, including akathisia. However, iloperidone can prolong the QTc interval on electrocardiogram. )
      • Asenapine: a clinical overview (It is administered as sublingual tablets in doses of 5 or 10 mg bid. It is well tolerated, with a dropout rate for adverse events similar to that of placebo. Asenapine is associated with a mean weight gain of less than 1 kg over a year and a relatively neutral effect on lipid and glucose levels. It can cause sedation and mild extrapyramidal side effects.)
      • Antipsychotics in the treatment of schizophrenia: an overview (Schizophrenia is characterized by positive, negative, cognitive, disorganization, and mood symptoms. Antipsychotics are the mainstay in the pharmacologic treatment of schizophrenia. Findings concerning efficacy for positive symptoms and disorganization suggest no consistent differences among available antipsychotics, with the exception of clozapine's superior efficacy for treatment-resistant schizophrenia. Although second-generation antipsychotics (SGAs) have generally been believed to be associated with a lower risk of EPS but a higher risk of metabolic adverse effects than first-generation agents (FGAs), the substantial variation in these and other side effects among agents within both classes indicates that it is not clinically useful to make a categorical distinction between FGAs and SGAs. )
      • Schizophrenia, psychotropic drugs and cognition (Differences between atypical and conventional drugs appear far less contrasted than initially suggested)
      • Time course of improvement with antipsychotic medication in treatment-resistant schizophrenia (The majority of improvement with antipsychotics occurs during the first 4 weeks)
      • Pharmacotherapy of schizophrenia (The typical-atypical classification is an outworn concept because there are pharmacological differences not only between the two groups but within the groups too. There are no significant differences among the antipsychotics with respect to efficiency but their side effect profiles are very different. )
      • Lurasidone: a new treatment option for schizophrenia (The incidence of extrapyramidal symptoms (excluding akathisia/restlessness) was greater with lurasidone (14.7%) than placebo (5.1%). Akathisia and somnolence were dose-related adverse events. Lurasidone appears to have relatively little effect on weight, plasma glucose or lipids to date. No evidence of QTc prolongation was seen and orthostatic hypotension was uncommon. Raised prolactin levels in short-term studies were dose-dependent, greater in females and occurred overall in 3.7 and 0.7% of lurasidone and placebo recipients, respectively.)
      • Management of schizophrenia in late life with antipsychotic medications: a qualitative review (Treatment of non-resistant, late-life schizophrenia with olanzapine and risperidone appears to be supported by the available evidence)
      • A review and Bayesian meta-analysis of clinical efficacy and adverse effects of 4 atypical neuroleptic drugs compared with haloperidol and placebo (clozapine, olanzapine, risperidone and aripiprazole show only small differences in overall efficacy. Olanzapine and clozapine produce the most weight gain and haloperidol produces the most extrapyramidal symptoms. Even aripiprazole and risperidone, however, induce considerable weight gain compared with placebo.)
      • Aripiprazole treatment for patients with schizophrenia: from acute treatment to maintenance treatment (The most current treatment guidelines for schizophrenia recommend more than 1 year of maintenance therapy after the first psychotic episode, and more than 5 years of maintenance therapy after multiple psychotic episodes. (Yet) Approximately two-thirds of such patients are known to relapse within 1 year and almost 90% of such patients may recur within 2 years.)
      • Treatment resistant schizophrenia and response to antipsychotics: a review (Treatment resistant schizophrenia usually is defined as at least 2 failed adequate antipsychotic trials (at chlorpromazine equivalent doses of = 1000 mg/day for = 6 weeks). Treatment response has been defined by a relative change in the representative scales (most commonly = 20% decrease in the Positive and Negative Syndrome Scale), but it sometimes included the absolute criteria such as post-treatment score of = 35 in the Brief Psychiatric Rating Scale or Clinical Global Impression-severity score of = 3 (mild or less severe). Social functioning has not been a primary outcome measure in past pivotal trials, and other important domains of the illness such as cognition and subjective perspectives have not been incorporated into definitions of treatment resistance or response. [Editor: It is a glaring omission not to use social/occupational/cognitive functioning in definitions of recovery/relapse.])
      • Adjunct mirtazapine for negative symptoms of schizophrenia (A few small studies found the addition of mirtazapine to antipsychotics to be effective at doses of 30 mg/day)
      • Dosing and switching strategies for paliperidone palmitate: based on population pharmacokinetic modelling and clinical trial data (The approved recommended initiation regimen for paliperidone palmitate is 234?mg on day 1 followed by 156?mg on day 8, each administered into the deltoid muscle, using a 1-inch 23-gauge needle in those weighing < 90 kg and a 1.5-inch 22-gauge needle in those weighing =90 kg. No oral supplementation is required. Monthly maintenance dosing is in the range of 39-234 mg; recommended dose of 117 mg injected into the deltoid (needle size is weight adjusted) or gluteal (using a 1.5-inch 22-gauge needle) muscle. The day 8 dose may be administered +/- 2 days and monthly doses +/- 7 days, without a clinically significant impact on plasma concentrations. In patients with mild renal impairment (creatinine clearance [CL(CR)]: 50-80 mL/min), dosage should be adjusted. No dose adjustment is required in patients with mild or moderate hepatic impairment; no data currently exist regarding severe hepatic impairment. Elderly patients with normal renal function should receive the same dosage as younger adult patients with normal renal function. Paliperidone palmitate can be initiated the day after discontinuing previous oral antipsychotic treatment. In patients switching from other long-acting injectable (LAI) antipsychotics, (including long-acting risperidone), paliperidone palmitate dosing should be initiated at the time of what would have been the next scheduled injection of the previous LAI, and continued monthly thereafter. )
      • Extent of attaining and maintaining symptom remission by antipsychotic medication in the treatment of chronic schizophrenia: evidence from the CATIE study (For patients with chronic schizophrenia, the CATIE study showed it was very difficult for them to attain symptom remission. At the start of the study, 16.2% of patients were already in symptomatic remission. During the following 18 months, only 11.7% attained and then maintained at least 6 months of symptomatic remission, and 55.5% (n = 623) experienced no symptom remission at any visit. Attaining and maintaining remission for 6 months was highest for the olanzapine (12.4%) medication group followed by the quetiapine (8.2%), perphenazine (6.8%), ziprasidone (6.5%), and risperidone (6.3%) groups.)
      • Difference in early prediction of antipsychotic non-response between risperidone and olanzapine in the treatment of acute-phase schizophrenia (In newly admitted patients with acute schizophrenia, non-response to risperidone using CGI-I at 2 weeks can predict subsequent response. It looks like there is significant response to olanzapine that doesn't occur until 4 weeks. Thus, clinicians may want to switch to another drug earlier when risperidone is the first drug, and later when olanzapine is the first drug.)
      • Predictors of response and remission in the acute treatment of first-episode schizophrenia patients--is it all about early response? (First-episode schizophrenia patients were treated for 43 days with either haloperidol or risperidone. Early response was defined as a = 30% improvement in the PANSS total score by week 2, response as a = 50% reduction in the PANSS total score from admission to discharge and remission according to the consensus criteria. 52% of the patients were responders and 59% remitters at discharge. A shorter duration of untreated psychosis (p=0.0167), a lower PANSS general psychopathology subscore (p<0.0001), and early treatment response (p=0.0002) were identified as significant predictors of remission.)
      • Early intervention for psychosis (6 studies of early intervention in the prodromal (prepsychotic) phase of schizophrenia found that nothing worked [olanzapine, cognitive behavioal therapy (CBT), family therapy, and seeing a specialized team].)
      • Bromperidol decanoate (depot) for schizophrenia (Patients allocated to fluphenazine decanoate and haloperidol decanoate had fewer relapses than those given bromperidol decanoate (NNH 6))
      • Old patients suffering from long-standing schizophrenia: clinical aspects (Firstly, some display high levels of all schizophrenic symptoms, while others experience changes in the symptom profile with aging, i.e. a reduction in positive symptoms and an increase in negative ones. Secondly, the occurrence of significant depressive symptoms among elderly patients with schizophrenia is well recognized. Lastly, aged persons with schizophrenia often have side effects due to long-term antipsychotic medications and medical co-morbidity, more untreated somatic disorders (diabetes, cardiovascular diseases) and higher mortality rates.)
      • Clinical usefulness of second-generation antipsychotics in treating children and adolescents diagnosed with bipolar or schizophrenic disorders (There is now evidence that aripiprazole, olanzapine, and risperidone are effective in the short-term treatment of children and adolescents with either early-onset schizophrenia or bipolar mania. "The use of clozapine should be strictly limited to patients with non-affective, psychotic symptoms who do not respond to aripiprazole, olanzapine, and risperidone." Due to the lack of research with quetiapine or ziprasidone; it is not possible to arrive at definitive conclusions.)
      • Aripiprazole versus placebo for schizophrenia (Despite the fact that 2585 people participated in nine randomised aripiprazole studies, we were unable to extract any usable data on death, service outcomes, general functioning, behavior, engagement with services, satisfaction with treatment; economic outcomes or cognitive functioning. In general, study attrition was very large for all studies over four weeks' duration. Fewer people left the aripiprazole group compared with those in the placebo group. Compared with placebo, aripiprazole significantly decreased relapse in both the short and medium term. )
      • Antipsychotic medication for early episode schizophrenia (People with early episode schizophrenia treated with typical antipsychotic medications are less likely to leave the study early, but more likely to experience medication-related side effects)
      • Specialised first-episode psychosis services: a systematic review of the literature (A two-year treatment period is not long enough to enable patients to maintain the improvements obtained during the active phase of an integrated treatment)
      • Iloperidone for the management of adults with schizophrenia (Prescribing information recommends a starting dosage of 1 mg twice daily and then titrated over 7 days to reach a target dosage of 12 to 24 mg/d. The titration is necessary to reduce the risk of orthostatic hypotension-related dizziness. Slow initial titration and twice-daily dosing are potential disadvantages.)
      • Pathways to aggression in schizophrenia affect results of treatment (Schizophrenia elevates the risk for aggressive behavior and violent crime. Clozapine has superior antiaggressive activity in comparison with other antipsychotics and with all other pharmacological treatments. It is usually effective when aggressive behavior is related to psychotic symptoms. However, in many patients, aggression is at least partly based on other factors such as comorbid substance use disorder, comorbid antisocial personality disorder/psychopathy, or current stress. These conditions which are sometimes underdiagnosed in clinical practice must be addressed by appropriate adjunctive psychosocial approaches or other treatments. Treatment adherence has a crucial role in the prevention of aggressive behavior in schizophrenia patients.)
      • Optimizing clozapine treatment (Plasma levels above the therapeutic threshold of 350-420 ng/ml are necessary to determine non-response to clozapine. Patients not responding to a high dose of clozapine should be tried on a lower dose. Augmentation with lamotrigine, antipsychotics, or electroconvulsive therapy may be beneficial in case of partial response to clozapine.)
      • Weight gain and changes in metabolic variables following olanzapine treatment in schizophrenia and bipolar disorder (The proportions of patients who gained at least 7%, 15% or 25% of their baseline weight with long-term exposure were 64%, 32% and 12%, respectively.)
      • Iloperidone, asenapine, and lurasidone: a brief overview of 3 new second-generation antipsychotics (Iloperidone, asenapine, and lurasidone are approved for the treatment of acute schizophrenia in adults, and asenapine is also approved for the maintenance treatment of schizophrenia and as a monotherapy or as an adjunct to lithium or valproate for the treatment of bipolar manic or mixed episodes. Asenapine is a sublingual preparation, in contrast to iloperidone and lurasidone, which are swallowed. Iloperidone and asenapine are dosed twice daily, in contrast to lurasidone, which is dosed once daily with food. Both asenapine and lurasidone can be initiated at a dose that is possibly therapeutic, but iloperidone requires 4 days of titration to reach its recommended target dose range. Although both asenapine and lurasidone can be associated with dose-related treatment-emergent akathisia, iloperidone is essentially free of extrapyramidal adverse effects or akathisia throughout its recommended dose range. Sedation and/or somnolence have been reported with each medication.)
      • Paliperidone extended-release: does it have a place in antipsychotic therapy? (In the absence of direct comparisons with risperidone, it remains difficult to come to a final verdict on the potential additional therapeutic benefits of Paliperidone extended-release which would justify its substantially higher costs as compared with risperidone (its parent compound).)
      • Risperidone in schizophrenia: is there a role for therapeutic drug monitoring? (The routine use of risperidone levels does not seem warranted in all patients with schizophrenia. Therapeutic drug monitoring of risperidone may be beneficial in certain circumstances, including assessing potential noncompliance and supporting compliance, ruling out therapeutic failure as a result of low drug concentrations, and identifying and managing drug interactions and adverse effects.)
      • Pharmacological augmentation strategies for schizophrenia patients with insufficient response to clozapine: a quantitative literature review (There is no combination of clozapine plus some other pharmaceutical agent that yet has been proven superior to clozapine alone)
      • Psychopharmacological treatment of schizophrenia: what do we have, and what could we get? (The effectiveness of second generation antipsychotics is comparable to that of first generation antipsychotics)
      • A tipping point in drug dosing in late-life schizophrenia (In treating individuals with late-life schizophrenia: avoid polypharmacy, gradual dose titration, and timely and thorough assessments of therapeutic and side effects.)
      • Typical and atypical antipsychotics: Is there a difference in their influence on neurocognition? (The reported positive, cognitive effects of atypical antipsychotics are slight, particularly compared to the severity of neurocognitive dysfunction found in schizophrenia. In clinical practice there seem to be no convincing reason for attaching much weight to any differential effects that typical or atypical antipsychotics may have on neurocognition.)
      • Iloperidone: A new drug for the treatment of schizophrenia (Iloperidone has established tolerability at recommended dosages of up to 24 mg daily; however, the dosage must be slowly increased over seven days, and twice-daily administration is required to avoid orthostatic hypotension. The most common adverse effects associated with iloperidone were dizziness, dry mouth, fatigue, nasal congestion, orthostatic hypotension, somnolence, tachycardia, and weight gain. Safety studies have also found that iloperidone increases the risk of Q-Tc interval prolongation, similar to that seen with ziprasidone. Minimal changes in glucose and lipid abnormalities were seen in short-term (4- and 6-week) and long-term (52-week) studies, indicating a low chance of metabolic disturbance with iloperidone. iloperidone lacks a clear benefit over other antipsychotic agents.)
      • Placebo response in clinical trials with schizophrenia patients (There is ample evidence of the impact of elevated placebo response in trials of major depression. Placebo response in schizophrenia trials has similarly increased over the past several years.)
      • Oral versus depot antipsychotic drugs for schizophrenia--a critical systematic review and meta-analysis of randomised long-term trials (Depot formulations significantly reduced relapses (NNT 10, P=0.0009), and dropout due to inefficacy. Limited data on non-adherence, rehospitalisation and dropout due to any reason and adverse events revealed no significant differences.)
      • Olanzapine pamoate for the treatment of schizophrenia (The side-effect profile is comparable to that of oral olanzapine. The most relevant adverse event is the post-injection delirium/sedation syndrome, occurring at a rate of 1.4% of patients. It requires administration by qualified personnel in settings where a post-injection observation period for 3 h by medical personnel is available.)
      • Managing suicide risk in patients with schizophrenia (Compared with the general population, these patients have an 8.5-fold greater risk of suicide. Clozapine is the only medication approved by the US FDA for preventing suicide in patients with schizophrenia. Selective serotonin receptor inhibitors (SSRIs) decrease depressive symptoms and suicidal thoughts in patients with schizophrenia.)
      • Risperidone versus other atypical antipsychotics for schizophrenia (The review currently includes 45 blinded RCTs with 7760 participants. Attrition from these studies was high (46.9%). The large proportion of participants leaving studies early and incomplete reporting of outcomes makes it difficult to draw firm conclusions. Risperidone produces somewhat more extrapyramidal side effects and clearly more prolactin increase than most other second generation antipsychotics.)
      • Evidence-based pharmacotherapy of schizophrenia (Withdrawing antipsychotics from patients who have been stable for up to 6 yr leads to more relapses than continuing medication. In effect, continuous treatment is more effective than intermittent strategies. )
      • An open, large, 6-month naturalistic study of outcome in schizophrenic outpatients, treated with olanzapine (The review currently includes 50 studies and 9476 participants. The overall attrition from the included studies was considerable (49.2%) leaving the interpretation of results problematic. Olanzapine may be a somewhat more efficacious drug than some other second generation antipsychotic drugs. This small superiority in efficacy needs to be weighed against a larger weight gain and associated metabolic problems than most other second generation antipsychotic drugs, except clozapine.)
      • Lurasidone for schizophrenia: a brief review of a new second-generation antipsychotic (Efficacy within the dose range of 40-120 mg/d was established in four 6-week, randomized, controlled trials. The recommended starting dose is 40 mg/d and the maximum recommended dose is 80 mg/d. Doses above 80 mg/d do not appear to confer added benefit and may be associated with a dose-related increase in certain adverse reactions such as somnolence and akathisia. Lurasidone is administered once daily with at least 350 calories of food in order to optimize bioavailability. Lurasidone is associated with minimal weight gain and no clinically meaningful alterations in glucose, lipids, or the ECG QT interval.)
      • Elderly patients with schizophrenia and depression: diagnosis and treatment (Augmentation of an antipsychotic medication with an antidepressant medication can be helpful for the elderly patient with schizophrenia and depressive symptoms)
      • The pharmacological management of violence in schizophrenia: a structured review (Although the increased risk of violent behavior in individuals with schizophrenia is now well-established, there is considerable uncertainty in pharmacological strategies to reduce this risk. The main findings included the association of nonadherence to antipsychotic medication to violent outcomes, a specific anti-aggressive effect of clozapine and short-term benefits of adjunctive beta-blockers. There was little evidence on the efficacy of adjunctive mood stabilizers, depot medication or electroconvulsive therapy.)
      • Lurasidone for schizophrenia: a review of the efficacy and safety profile for this newly approved second-generation antipsychotic (Recommended starting dose of 40 mg/day administered once daily with food (=350 calories). The maximum recommended dose is 80 mg/day. NNT vs. placebo was 3-6 for response as defined by =20% reduction in psychopathological rating scale total scores from baseline. Response as defined by a =30% improvement yielded NNTs ranging from 7 to 13. The most common adverse events in the clinical trials were somnolence (broadly defined), akathisia, nausea, parkinsonism and agitation. Lurasidone is associated with minimal weight gain and no clinically meaningful alterations in glucose, lipids, prolactin or the ECG QT interval. Principal advantages over some other second-generation antipsychotics are lurasidone's highly favourable metabolic profile and once-daily dosing regimen.)
      • The treatment of cognitive impairment in schizophrenia (No treatment has yet demonstrated efficacy in large replication trials)
      • Predictors of relapse in Chinese schizophrenia patients: a prospective, multi-center study (The study confirmed the importance of maintenance medication in preventing relapse in Chinese schizophrenia patients underscoring the risk of relapse associated with lack of treatment adherence, severe side effects and the patients' paranoid attitude.)
    • Psychological Therapies
      • Schizophrenia, cognition and psychoeducation (Cognitive remediation targets elementary cognitive impairment, mostly with repetitive cognitive tasks, and studies show an improvement in these specific tasks, but without positive effect on functional and social aspects of the illness. (Whereas) overall approaches, such as psychoeducation or therapeutic education, obtain real gains in quality of life for the patients, autonomy and clinical improvement.)
      • A randomized, controlled trial of computer-assisted cognitive remediation for schizophrenia (Cognitive remediation for people with schizophrenia was effective in improving memory, concentration and executive functioning. "However, there were no significant benefits of cognitive remediation on non-verbal working memory and learning and speed of processing or functional outcome measures." Thus this computer-assisted training did not cause any clinically significant improvement in psychosocial functioning. [Editor: Psychosocial research has shown that patients do significantly benefit from exercise, social skills training, occupational therapy, music therapy and psychoeducation; whereas computer-assisted cognitive remediation appears to accomplish little.])
    • Other Therapies
    • Miscellaneous
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