What are the primary goals of care for schizophrenia?

Goals of Care for Schizophrenia

The primary goals of care for schizophrenia are to reduce mortality and morbidity, improve quality of life and treatment outcomes, control symptoms, prevent relapse, and restore functioning to promote recovery. 1

Core Treatment Objectives

Mortality and Morbidity Reduction

• Reducing premature death is paramount, as individuals with schizophrenia have standardized mortality ratios 2-4 times higher than the general population, with shortened lifespans. 1
• Suicide prevention is critical, as 4-10% of persons with schizophrenia die by suicide, with highest rates among males in early illness stages. 1
• Physical health monitoring and intervention must be prioritized to address obesity, diabetes, hyperlipidemia, smoking, and disparities in preventive healthcare access that contribute to excess mortality. 1

Symptom Control Across All Domains

• Target positive symptoms (hallucinations, delusions, disorganized behavior) through antipsychotic medications. 1
• Address negative symptoms (apathy, avolition, anhedonia, social withdrawal) which significantly impact functioning but respond less robustly to medications alone. 1, 2
• Improve cognitive function (executive functioning, information processing, attention, working memory) as these deficits are core features that significantly impact quality of life and functional outcomes. 2

Relapse Prevention

• Preventing relapse is essential, as each relapse worsens prognosis and increases risk of treatment resistance, hospitalization, and functional decline. 3, 4, 5
• Continuous antipsychotic therapy is recommended rather than intermittent treatment, as medication nonadherence is one of the most important risk factors for relapse and hospitalization. 3, 4, 6

Functional Recovery and Quality of Life

• Restoration of functioning beyond symptom control includes reintegration into society, regaining independence, improving social and occupational functioning, and enhancing daily activities. 7, 4, 6
• Quality of life improvement encompasses overall mental and physical well-being rather than simply absence of illness. 3, 7, 6

Comprehensive Treatment Framework

Patient-Centered Assessment and Planning

• Comprehensive initial assessment must include the patient's goals and preferences for treatment, psychiatric symptoms, trauma history, substance use assessment, physical health evaluation, psychosocial and cultural factors, mental status examination with cognitive assessment, and suicide/aggression risk assessment. 1
• Use quantitative measures to identify and determine severity of symptoms and functional impairments that will be treatment targets. 1
• Document a comprehensive, person-centered treatment plan that includes evidence-based pharmacological and nonpharmacological treatments. 1

Pharmacological Interventions

• Antipsychotic medication is the cornerstone and should be initiated with monitoring for effectiveness and side effects. 1
• Continue antipsychotic treatment long-term in patients whose symptoms have improved, preferably with the same medication that achieved response. 1
• Use clozapine for treatment-resistant schizophrenia (patients not responding to at least two other antipsychotics) and when suicide risk remains substantial despite other treatments. 1, 8
• Select agents with minimal anticholinergic properties to avoid cognitive blunting. 2
• Avoid high-dose therapy or polypharmacy as these may worsen cognitive function through increased sedation and anticholinergic effects. 2

Psychosocial Interventions

• Cognitive remediation therapy is strongly recommended (1B evidence rating) for improving cognitive function. 2
• Cognitive-behavioral therapy for psychosis (CBTp) demonstrates modest but lasting positive effects on cognition and symptoms (1B evidence rating). 2
• Family intervention programs combined with medication significantly decrease relapse rates by addressing communication, problem-solving skills, and relapse prevention. 1, 9
• Social skills training focused on conflict resolution, communication strategies, and vocational skills improves functioning. 1, 9
• Psychoeducation and supported employment services are recommended (1B rating) to improve overall functioning. 2, 9

Critical Implementation Considerations

Early Intervention

• Time is cognition: Early effective treatment is vital in preserving patients' cognition and ability to function, as longer duration of untreated illness is a modifiable risk factor for poor outcomes. 1, 3

Adherence Optimization

• Consider long-acting injectable (LAI) antipsychotics as they offer reliable drug delivery, uncover nonadherence and pseudo-resistance, and reduce relapse risk and mortality. 3, 4
• Maintain consistent therapeutic relationships to monitor for relapse and nonadherence. 9

Comorbidity Management

• Address co-occurring psychiatric disorders including substance use disorders, which contribute significantly to morbidity and mortality. 1, 9

Common Pitfalls to Avoid

• Do not use traditional psychotherapy alone, as it is ineffective; learning-based therapies with cognitive-behavioral strategies are required. 9
• Do not treat in isolation without addressing comorbid conditions, environmental stressors, and developmental needs. 9
• Do not overlook physical health monitoring, as disparities in preventive care contribute substantially to excess mortality. 1
• Do not accept inadequate treatment trial duration before declaring treatment failure. 9