Treatment of the patient with long-term schizophrenia

At most, 15% of patients in Western countries remain free of relapse after their first episode of schizophrenia (Crow et al, 1986). Like many chronic illnesses, schizophrenia can be controlled by appropriate treatment, but there may be a gradual deterioration over time. This encompasses problems such as loss of self-care, communication and community skills; negative symptoms of poverty of affect and ideation; cognitive impairment; behaviour problems such as aggression; and poorly controlled positive symptoms. Deterioration often appears consequent upon repeated relapse. Indeed, the prognosis of schizophrenia may have improved significantly following the introduction of neuroleptics (see McKenna, 1994) because of their marked prophyl actic effect in preventing relapse. One analysis of 24 placebo-controlled studies of continuing antipsychotic treatment showed that patients relapsed more frequently on placebo than on active medication: active treatment over three years reduced the risk of relapse almost threefold (Davis, 1975). Two issues are, therefore, germane to the longterm treatment of schizophrenia. The first is the prevention of relapses, most of which are caused by non-compliance (Davis et al, 1994), and the second is the management of unresolved symp toms and social deficits. Optimal management should include a spectrum of approaches from sophisticated use of medication to appropriate psychotherapy. Its rationale is essentially rehab ilitative, comprising assessment of individual difficulties plus targeted interventions. If the patient cannot be returned to adequate function, ongoing support and care are necessary. Continuous management of this nature is best facilitated by a multi-disciplinary framework, currently exemplified by the Care Programme Approach (CPA).