MHM Magazine

12 | MENTALHEALTHMATTERS | Issue 4 | 2021 MHM conditions. Professor Chiliza suggests that in practice, staging would mean identifying chronic mental illnesses early and administering more intensive treatments as close to the onset as possible in the hope of preventing the condition from progressing to the next stage. This would contrast with the traditional approach of diagnose, prescribe and follow- up a few months later. But with this comes several challenges, chief among them, how do we get schizophrenia patients in early enough to maximize treatment in the beginning stages of the condition? IDENTIFYING SCHIZOPHRENIA EARLY Identifying schizophrenia early is a challenge. In the South African context, this is especially so. Professor Chiliza illustrates that research done in KwaZulu-Natal and Cape Town showed that on average, the delay between the onset of psychotic symptoms and a patient receiving treatment is twelve months. This average was identified in the big cities, which indicates that in rural areas the delay may be even longer. The greatest contributing factor here being lack of awareness of the signs and symptoms of the condition among the general population. Internationally, there are several attempts at tackling this problem. The International Early Psychosis Association, which is led by psychiatrists and psychologists determined to overcome this challenge, has two primary focuses: first, reducing the delay in treatment, and second, the provision of intensive treatment during the critical period. In In some European countries there are awareness campaigns aimed at raising awareness of the signs and symptoms of schizophrenia and even has dedicated hotlines where people who suspect they are experiencing psychosis can call to get help. The results of such campaigns have shown to reduce the delay in patients seeking treatment. Once a patient is identified with having schizophrenia, the focus shifts to provision of intensive treatment during the critical period. INTENSIVE TREATMENT DURING THE CRITICAL PERIOD In many high-income regions around the world, such as the UK, Australia and much of Europe, there are now early intervention services, but in the United States the approach has been different. Studies in the US have been focused on making comparative analyses between various interventions around the world with the aim of identifying the best approaches to treatment outside of large academic institutions. The Recovery After Initial Schizophrenia Episode (RAISE) project compared comprehensive treatment, with care typically found in community settings. The study found that it’s vital “to do the right thing at the right time”. While the study found that it’s possible to implement successful treatments in community settings, comprehensive treatment is preferred. An important take away from this were the ingredients involved in providing sufficient comprehensive care. INGREDIENTS OF COMPREHENSIVE CARE The point of departure for treatment and management of schizophrenia is the biopsychosocial approach, meaning that patients should be receiving treatment that cuts across these three spheres. To treat the condition effectively in the early stages, comprehensive care should include personalised medication management, family psychoeducation, individual psychotherapy, and supported employment and education. Personalised medication treatment : While studies have found that most anti-psychotics are equal in terms of efficacy, personalised medication management means identifying the tolerance of specific side effects in individual patients and considering medications in line with this. International guidelines are clear on the fact that newer anti-psychotics should take preference over older ones due to improved safety profiles, and that healthcare providers should stay away from olanzapine as a first-line anti-psychotic, as it’s associated with significant weight gain, which can result in diabetes and hypertension. LONG ACTING INJECTABLES Another approach to treatment which appears to yield positive results is the use of long-acting injectables, especially at the onset of the condition. While long acting injectables have previously been found to be less effective in later stage schizophrenia, results during early stages have been promising. During his PhD at Stellenbosch University, Professor Chiliza led a study on the use of long-acting antipsychotics. While resources for psychotherapy were low, other means of comprehensive treatment along with long- acting injectable anti-psychotics were administered to patients. Family psychoeducation, and constant monitoring by nurses and following up with patients was implemented with the aim of observing how well patients responded. The study found that most patients did exceptionally well. While some had to stop treatment due to side effects, 62% of patients were able to stay on the treatment. By the end of 12 months, 60% of patients were in remission (low or no symptoms sustained for six months), which compared extremely favorably to most other studies involving the administering of oral medications as the primary treatment. PREVENTING RELAPSE Another important aspect of management of schizophrenia is to try to prevent relapse, as evidence shows that with each subsequent relapse, the condition progresses and becomes more severe. Healthcare providers often struggle to get their patients to pre-relapse conditions once a relapse has occurred. Several studies have looked at this and found that when early intervention is provided to first episode schizophrenia patients, their response rate is much better