Schizophrenia: symptoms, causes and treatment

• Schizophrenia is a mental health condition that causes psychosis and can bring significant disability. It can affect every area of life, including personal, family, social, educational and working life.
• Stigma, discrimination and human rights violations against people with schizophrenia are common.
• More than two in three people with psychosis worldwide do not receive specialist mental health care.
• There is a range of effective care for people with schizophrenia, and at least one in three people with schizophrenia will be able to fully recover.

These facts come from the World Health Organization (WHO). They show how important it is for people with schizophrenia to be treated under the care of a psychiatrist. In this article we look at schizophrenia more closely.

Symptoms of schizophrenia

Schizophrenia involves significant changes in how a person perceives reality and in their behaviour. The symptoms are:

Delusions

The person holds fixed beliefs that something is true, despite evidence to the contrary, and keeps insisting on them.

Persistent hallucinations

The person may hear, smell, see, touch or feel things that are not there.

Experiences of influence, control or passivity

The person may believe that their feelings, impulses, actions or thoughts are not their own, or that their thoughts are being broadcast to others.

• Disorganised thinking, often seen as jumbled or irrelevant speech.
• Highly disorganised behaviour: for example, doing things that seem odd or purposeless, or having unpredictable or inappropriate emotional responses that make it hard to organise behaviour.
• "Negative symptoms", such as very limited speech, restricted experience and expression of emotions, an inability to feel interest or pleasure, and social withdrawal.
• Extreme agitation or slowed movement, or holding unusual postures.
• People with schizophrenia also often have ongoing difficulties with thinking skills such as memory, attention and problem-solving.

Some people with schizophrenia have periods of getting worse and better throughout their lives.

Facts and figures

Schizophrenia affects about 24 million people, or 1 in 300 people (0.32%) worldwide. Among adults the rate is 1 in 222 (0.45%). It is less common than many other mental health conditions. It most often begins in the late teens and twenties, and earlier in men than in women.

People with schizophrenia are 2 to 3 times more likely to die early than the general population. This is often due to physical illnesses such as cardiovascular, metabolic and infectious diseases.

Causes of schizophrenia

Schizophrenia is thought to result from an interaction between genes and a range of environmental factors. Psychosocial factors may also affect its onset and course. Heavy cannabis use is linked with a higher risk.

Services for people with schizophrenia

Most people with schizophrenia around the world do not receive mental health care, even though about 50% of people in psychiatric hospitals have a diagnosis of schizophrenia. Only 31.3% of people with psychosis receive specialist mental health care. Most mental health resources are spent inefficiently on care in psychiatric hospitals.

There is clear evidence that psychiatric hospitals do not provide the care people with mental health conditions need, and that they often violate the basic human rights of people with schizophrenia. Efforts to move care from institutions into the community should be expanded and accelerated, starting with a range of good-quality community mental health services. Community options include integrating care into primary health care and general hospitals, community mental health centres, day centres, supported housing and outreach services for support at home. Involving the person with schizophrenia, their family and the wider community in support is important.

Managing and supporting schizophrenia

There is a range of effective care for people with schizophrenia, including medication, psychoeducation, family interventions, cognitive behavioural therapy and psychosocial rehabilitation (for example, life skills training). Assisted living, supported housing and supported employment are essential options that should be available. A recovery-oriented approach, which gives people a say in decisions about their treatment, is also essential for people with schizophrenia and their families or carers.

Treatment of schizophrenia

Schizophrenia often needs long-term, and sometimes lifelong, treatment, even when symptoms have eased. Medication and psychosocial treatment can help manage the illness. In some cases, a hospital stay may be needed.

A psychiatrist experienced in treating schizophrenia usually guides treatment. The team may also include a psychologist, a social worker, a psychiatric nurse and possibly a case manager to coordinate care. This full-team approach may be available in clinics that specialise in schizophrenia.

CBT for schizophrenia

Cognitive behavioural therapy (CBT) is a structured, problem-focused approach that teaches people with schizophrenia a range of coping skills to manage difficult situations. It is usually delivered in weekly sessions over several months; NICE guidelines recommend at least 16 sessions.

Medicines for schizophrenia

The main medicines for schizophrenia are antipsychotics. Older ones are called "first-generation" or "typical" antipsychotics (such as haloperidol), and newer ones "second-generation" or "atypical". The psychiatrist chooses the medicine based on each person's symptoms, side effects and circumstances. Some second-generation antipsychotics (with US brand names) are:

• Aripiprazole (Abilify), and its long-acting injection aripiprazole lauroxil (Aristada)
• Asenapine (Saphris)
• Brexpiprazole (Rexulti)
• Cariprazine (Vraylar)
• Clozapine (Clozaril)
• Iloperidone (Fanapt)
• Lumateperone (Caplyta)
• Lurasidone (Latuda)
• Olanzapine (Zyprexa), and the combination olanzapine/samidorphan (Lybalvi)
• Paliperidone (Invega), and its long-acting injections (Invega Sustenna and Invega Trinza)
• Quetiapine (Seroquel)
• Risperidone (Risperdal)
• Ziprasidone (Geodon)

In 2024, the FDA approved xanomeline-trospium (Cobenfy). Unlike earlier medicines, it acts on muscarinic receptors rather than dopamine receptors, and it is the first new mechanism of drug treatment for schizophrenia in decades.

Note: clozapine is the only FDA-approved medicine for treatment-resistant schizophrenia. It needs regular blood tests because it can lower the white blood cell count. Do not start or stop any of these medicines without your psychiatrist's advice.

Schizophrenia and the risk of violence

Most people with schizophrenia are not violent. In general, people with schizophrenia are more likely to be harmed by others than people without the illness. The risk of self-harm and of violence towards others is higher when the illness is untreated or when it occurs with alcohol or drug misuse. Helping people with symptoms get treatment as early as possible is very important.