What are the primary goals of care for schizophrenia?

Goals of Care for Schizophrenia

The primary goals of care for schizophrenia are reducing premature mortality, preventing suicide, optimizing physical health, controlling psychiatric symptoms, and improving functional capacity and quality of life. 1

Mortality Reduction as the Top Priority

Reducing premature death must be the foremost objective, as individuals with schizophrenia have standardized mortality ratios 2-4 times higher than the general population, with significantly shortened lifespans. 1, 2

Suicide Prevention

• Suicide accounts for 4-10% of deaths in persons with schizophrenia, with highest rates among males in early illness stages, making suicide prevention a critical treatment goal. 1
• Clozapine should be used when suicide risk remains substantial despite other treatments. 1

Physical Health Optimization

• Obesity, diabetes, hyperlipidemia, and smoking must be actively monitored and addressed, as cardiovascular disease and metabolic complications are major contributors to excess mortality. 1, 2
• Disparities in preventive healthcare access significantly contribute to excess mortality and require active intervention. 1, 2

Symptom Control and Relapse Prevention

Controlling symptoms and preventing relapse are essential intermediate goals that directly impact long-term outcomes, as each relapse worsens prognosis and increases the risk of treatment resistance. 3, 4

Pharmacological Management

• Antipsychotic medication is the cornerstone of treatment and should be initiated with monitoring for effectiveness and side effects. 1
• Continue long-term antipsychotic treatment with the same medication that achieved response, as discontinuation often leads to relapse. 1, 2
• Use clozapine for treatment-resistant schizophrenia after failure of two adequate trials of other antipsychotics. 1, 5

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

Functional Recovery and Quality of Life

Beyond symptom reduction, treatment must focus on maintaining functional capacity, promoting social reintegration, regaining independence, and improving quality of life. 3, 6, 7

Cognitive Function Preservation

• Cognitive remediation therapy is strongly recommended (1B evidence) for improving cognitive function, which directly impacts quality of life and independence. 1, 2
• Cognitive-behavioral therapy for psychosis demonstrates modest but lasting positive effects on cognition and symptoms (1B evidence). 1, 2, 5

Social and Occupational Functioning

• Family intervention programs combined with medication significantly decrease relapse rates by addressing communication, problem-solving skills, and relapse prevention. 1, 2
• Psychoeducation for both patient and family has strong evidence (1B rating) for improving overall functioning and reducing relapse rates. 5

Comprehensive Person-Centered Care

A comprehensive initial assessment must include the patient's goals and preferences for treatment, along with 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

Co-occurring Conditions

• Address co-occurring psychiatric disorders, including substance use disorders, which contribute significantly to morbidity and mortality. 1
• Substance abuse is a modifiable risk factor for poor outcomes and must be actively treated. 3

Treatment Planning

• Document a comprehensive, person-centered treatment plan that includes evidence-based pharmacological and nonpharmacological treatments. 1
• The treatment approach should embrace overall mental and physical well-being rather than simply the absence of illness. 7

Critical Pitfalls to Avoid

• Do not delay effective treatment, as longer duration of untreated illness is associated with worse cognitive outcomes and functional capacity. 1
• Do not neglect physical health monitoring, as cardiovascular and metabolic complications are the leading causes of premature death, not psychiatric symptoms alone. 1, 2
• Do not underestimate suicide risk throughout the illness course, even in patients who appear stable, as risk persists throughout life. 2
• Do not discontinue antipsychotics prematurely, as this is one of the most important risk factors for relapse and hospitalization. 3, 6