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The conclusion from a meta-analysis of studies of the economic burden of schizophrenia was that the enormous burden is suggestive of the inadequate provision of healthcare services to patients with schizophrenia.[[1]] Better resource allocation and policy-orientated research is seen as a solution to this problem. The article in this New Zealand Medical Journal[[2]] provides an excellent summary of current state of play in New Zealand. It highlights the health, social and economic outcomes for those with the disorder.

Recent exploration of what matters for people with schizophrenia highlighted the need to feel safe, the opportunity for employment, access to good healthcare support and having meaningful social relationships.[[3]] These factors were very similar to findings of a local (unpublished) review of the long-term outcomes for people who have been through our anti-psychotic treatment trials.

The age of the institution may have passed but the messages emerging from work such as that of Sheree Gibb et al[[2]] might be that we still have a long way to go to deliver healthcare, social and occupational supports to people with schizophrenia that does not disadvantage them or stigmatise them.

There are good guidelines for the treatment of schizophrenia.[[4]] I suspect the problem is that we do not deliver according to these best evidence-guided recommendations.

The time between onset of symptoms and beginning treatment remains disappointingly high. We are used to strong pushes for the early identification of cancer because there is strong evidence that early detection and appropriate evidence-based interventions significantly alter the disease course. We do not see such initiatives for psychosis. An elegant Scandinavian study which was set up to examine differences with true early detection of psychosis showed that early treatment for first psychosis had positive effects on clinical and functional outcomes.[[5]]

Reasons for delay include the stigma attached to any diagnosis of a mental illness, and especially to that of schizophrenia. It is also well recognised[[6]] that the disorder itself causes a lack of awareness of the symptoms (anosognosia), such that an individual experiencing psychotic symptom will not have awareness of these. We have a long way to go the shift public attitude towards mental illness and to create safe environments where the young people experiencing their first episode of a psychotic disorder (illness onset is typically late adolescence to early adulthood) can present. They will often be reliant on family or close friends to assist them recognise a problem and seek help for it; thus the point of care needs to be user friendly for these support people also.

Though I do not have the data to support my clinical impression, it is likely that many presentations with schizophrenia are in crisis situations where there are concerns about the risk of the person with the disorder. They do not get seen in primary health settings, where one would ideally want an illness like this to be assessed and treated. By the time they present there is usually considerable disruption in their lives; relationships are challenged or disrupted; usual occupation or education and recreational pursuits have ceased. This loss of the usual social supports will coincide with a time of immense personal angst; the traumatic experience of identity dissolution, boundary loss and the like should not be underestimated. One only has to consider what it must be like to have some sinister voice that continues to berate you or threaten you; then, if you are brave enough to mention it to others, you then get told they cannot hear the voice—how do you assimilate that?

For my goal of dedicated public health campaigns that target early identification of and rapid interventions for those at risk of schizophrenia, it will be necessary to address the pervasive public prejudice and discrimination. This is no simple task and the available worldwide evidence of success for anti-stigma campaigns for mental illness is not reassuring.[[7,8]] Strategies are generally described as contact with consumers, education campaigns and social activism and protest. Both contact approaches and education campaigns do have small to medium effect sizes. There is no study of social activism approaches.

I am hopeful that dissemination of the costs of schizophrenia, both to the people who experience it and to the population as a whole, might stimulate people in influence to take the challenge to address the public health importance of reducing stigma, thereby enhancing the possibility of early access to best evidenced treatments.

Why we want to treat early and maintain good treatment is because it not only produces better outcomes regarding illness experience and function, but because it is also linked to arresting (and perhaps improving) loss of cortical matter[[9]] and decreasing the effect of schizophrenia on reducing life expectancy.[[10]] A German study[[11]] carefully reviewed the achievement of remission (using well defined criteria[[12]]) and suggests there is good reason for expectation of positive outcome from good treatment.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Wayne Miles: Clinical Director Research and Knowledge, Waitemata DHB; Clinical Associate Professor Department of Psychological Medicine, University of Auckland

Acknowledgements

Correspondence

Associate Prof Wayne Miles, Clinical Director Research and Knowledge, Waitemata DHB; Clinical Associate Professor Department of Psychological Medicine, University of Auckland

Correspondence Email

Wayne.miles@waitematadhb.govt.nz

Competing Interests

Nil.

1) Chong HY, Teoh SL, Wu DB-C, Kotirum S,Chiou C-F, Chaiyakunapruk N. Global economic burden of schizophrenia: a systematic review. Neuropsychiatric Diseases and Treatment. 2016; 12: 357-73.

2) Gibb S, Brewer N, Bowden N. Social impacts and costs of schizophrenia: a national cohort study using New Zealand linked administrative data. N Z Med J. 2021; 1537(134):66-83

3) Lloyd H, Lloyd J, Fitzpatrick R, Peters M. The role of life context and self-defined well-being in the outcomes that matter to people with a disagnosis of schizophrenia. Health Expectations. 2017; 20: 1061-72.

4) Galletly C, Castle D, Dark F, Humberstone V, Jablensky A, Killackey E, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Australian and New Zealand Journal of Psychiatry. 2016; 50 (5); 410-72.

5) Larsen TK, Melle I, Auestad B, Haahr U, Joa I, Johannessen O, et al. Early detection of psychosis: positive effects on 5-year outcome. Psychological Medicine. 2011; 41: 1461-69.

6) Pia L, Tamietto M. Unawareness in schizophrenia: Neuropsychological and neuroanatomical findings. Psychiatry and Clinical Neurosciences. 2006; 60: 531-7.

7) Corrigan PW, Morris SB, Michaels PJ, Rafacz JD, Rusch N. Challenging the public stigma of mental illness: a meta-analysis of outcome studies. Psychiatric Services. 2012; 63: 963-73.

8) Morgan AJ, Reavley NJ, Ross A, Too LS, Jorm AF. Intervetions to reduce stigma towards people with severe mental illness: Systematic review and meta-analysis. Journal of Psychiatric Research. 2018; 103:120-33.

9) van Haren NEM, Hulshoff Pol HE, Schnack HG, Cahn W, Mandl RCW, Collins DL, et al.Focal grey matter changes in schizophrenia across the course of the illness: a 5-year follow up study. Neuropsychopharmacology. 2007; 32: 2057-66.

10) Tiihonen J, Lonnqvist J, Wahlbeck K, Klaukka T, Niskanen L, Tanskanen A et al. 11 Year follow up of mortality in patients with schizophrenia: a population-based study (FIN11 study). The Lancet. 2009; 374:620-7.

11) Schennach R, Riedal M, Obermeir M, Jager, M, Schmauss M, Laux G et al.Remission and recovery and their predictors in schizophrenia spectrum disorders: Results from a 1 year follow-up naturalistic trial. Psychiatric Q. 2012; 83: 187-207.

12) Andreasen NC, Carpenter WT, Kane JM, Lasser RA, Marder SR, Weinberger DR, et al. Remission in schizophrenia: propsed criteria and rationale for consensus. American Journal of Psychiatry. 2005: 162: 441-9.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

The conclusion from a meta-analysis of studies of the economic burden of schizophrenia was that the enormous burden is suggestive of the inadequate provision of healthcare services to patients with schizophrenia.[[1]] Better resource allocation and policy-orientated research is seen as a solution to this problem. The article in this New Zealand Medical Journal[[2]] provides an excellent summary of current state of play in New Zealand. It highlights the health, social and economic outcomes for those with the disorder.

Recent exploration of what matters for people with schizophrenia highlighted the need to feel safe, the opportunity for employment, access to good healthcare support and having meaningful social relationships.[[3]] These factors were very similar to findings of a local (unpublished) review of the long-term outcomes for people who have been through our anti-psychotic treatment trials.

The age of the institution may have passed but the messages emerging from work such as that of Sheree Gibb et al[[2]] might be that we still have a long way to go to deliver healthcare, social and occupational supports to people with schizophrenia that does not disadvantage them or stigmatise them.

There are good guidelines for the treatment of schizophrenia.[[4]] I suspect the problem is that we do not deliver according to these best evidence-guided recommendations.

The time between onset of symptoms and beginning treatment remains disappointingly high. We are used to strong pushes for the early identification of cancer because there is strong evidence that early detection and appropriate evidence-based interventions significantly alter the disease course. We do not see such initiatives for psychosis. An elegant Scandinavian study which was set up to examine differences with true early detection of psychosis showed that early treatment for first psychosis had positive effects on clinical and functional outcomes.[[5]]

Reasons for delay include the stigma attached to any diagnosis of a mental illness, and especially to that of schizophrenia. It is also well recognised[[6]] that the disorder itself causes a lack of awareness of the symptoms (anosognosia), such that an individual experiencing psychotic symptom will not have awareness of these. We have a long way to go the shift public attitude towards mental illness and to create safe environments where the young people experiencing their first episode of a psychotic disorder (illness onset is typically late adolescence to early adulthood) can present. They will often be reliant on family or close friends to assist them recognise a problem and seek help for it; thus the point of care needs to be user friendly for these support people also.

Though I do not have the data to support my clinical impression, it is likely that many presentations with schizophrenia are in crisis situations where there are concerns about the risk of the person with the disorder. They do not get seen in primary health settings, where one would ideally want an illness like this to be assessed and treated. By the time they present there is usually considerable disruption in their lives; relationships are challenged or disrupted; usual occupation or education and recreational pursuits have ceased. This loss of the usual social supports will coincide with a time of immense personal angst; the traumatic experience of identity dissolution, boundary loss and the like should not be underestimated. One only has to consider what it must be like to have some sinister voice that continues to berate you or threaten you; then, if you are brave enough to mention it to others, you then get told they cannot hear the voice—how do you assimilate that?

For my goal of dedicated public health campaigns that target early identification of and rapid interventions for those at risk of schizophrenia, it will be necessary to address the pervasive public prejudice and discrimination. This is no simple task and the available worldwide evidence of success for anti-stigma campaigns for mental illness is not reassuring.[[7,8]] Strategies are generally described as contact with consumers, education campaigns and social activism and protest. Both contact approaches and education campaigns do have small to medium effect sizes. There is no study of social activism approaches.

I am hopeful that dissemination of the costs of schizophrenia, both to the people who experience it and to the population as a whole, might stimulate people in influence to take the challenge to address the public health importance of reducing stigma, thereby enhancing the possibility of early access to best evidenced treatments.

Why we want to treat early and maintain good treatment is because it not only produces better outcomes regarding illness experience and function, but because it is also linked to arresting (and perhaps improving) loss of cortical matter[[9]] and decreasing the effect of schizophrenia on reducing life expectancy.[[10]] A German study[[11]] carefully reviewed the achievement of remission (using well defined criteria[[12]]) and suggests there is good reason for expectation of positive outcome from good treatment.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Wayne Miles: Clinical Director Research and Knowledge, Waitemata DHB; Clinical Associate Professor Department of Psychological Medicine, University of Auckland

Acknowledgements

Correspondence

Associate Prof Wayne Miles, Clinical Director Research and Knowledge, Waitemata DHB; Clinical Associate Professor Department of Psychological Medicine, University of Auckland

Correspondence Email

Wayne.miles@waitematadhb.govt.nz

Competing Interests

Nil.

1) Chong HY, Teoh SL, Wu DB-C, Kotirum S,Chiou C-F, Chaiyakunapruk N. Global economic burden of schizophrenia: a systematic review. Neuropsychiatric Diseases and Treatment. 2016; 12: 357-73.

2) Gibb S, Brewer N, Bowden N. Social impacts and costs of schizophrenia: a national cohort study using New Zealand linked administrative data. N Z Med J. 2021; 1537(134):66-83

3) Lloyd H, Lloyd J, Fitzpatrick R, Peters M. The role of life context and self-defined well-being in the outcomes that matter to people with a disagnosis of schizophrenia. Health Expectations. 2017; 20: 1061-72.

4) Galletly C, Castle D, Dark F, Humberstone V, Jablensky A, Killackey E, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Australian and New Zealand Journal of Psychiatry. 2016; 50 (5); 410-72.

5) Larsen TK, Melle I, Auestad B, Haahr U, Joa I, Johannessen O, et al. Early detection of psychosis: positive effects on 5-year outcome. Psychological Medicine. 2011; 41: 1461-69.

6) Pia L, Tamietto M. Unawareness in schizophrenia: Neuropsychological and neuroanatomical findings. Psychiatry and Clinical Neurosciences. 2006; 60: 531-7.

7) Corrigan PW, Morris SB, Michaels PJ, Rafacz JD, Rusch N. Challenging the public stigma of mental illness: a meta-analysis of outcome studies. Psychiatric Services. 2012; 63: 963-73.

8) Morgan AJ, Reavley NJ, Ross A, Too LS, Jorm AF. Intervetions to reduce stigma towards people with severe mental illness: Systematic review and meta-analysis. Journal of Psychiatric Research. 2018; 103:120-33.

9) van Haren NEM, Hulshoff Pol HE, Schnack HG, Cahn W, Mandl RCW, Collins DL, et al.Focal grey matter changes in schizophrenia across the course of the illness: a 5-year follow up study. Neuropsychopharmacology. 2007; 32: 2057-66.

10) Tiihonen J, Lonnqvist J, Wahlbeck K, Klaukka T, Niskanen L, Tanskanen A et al. 11 Year follow up of mortality in patients with schizophrenia: a population-based study (FIN11 study). The Lancet. 2009; 374:620-7.

11) Schennach R, Riedal M, Obermeir M, Jager, M, Schmauss M, Laux G et al.Remission and recovery and their predictors in schizophrenia spectrum disorders: Results from a 1 year follow-up naturalistic trial. Psychiatric Q. 2012; 83: 187-207.

12) Andreasen NC, Carpenter WT, Kane JM, Lasser RA, Marder SR, Weinberger DR, et al. Remission in schizophrenia: propsed criteria and rationale for consensus. American Journal of Psychiatry. 2005: 162: 441-9.

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

The conclusion from a meta-analysis of studies of the economic burden of schizophrenia was that the enormous burden is suggestive of the inadequate provision of healthcare services to patients with schizophrenia.[[1]] Better resource allocation and policy-orientated research is seen as a solution to this problem. The article in this New Zealand Medical Journal[[2]] provides an excellent summary of current state of play in New Zealand. It highlights the health, social and economic outcomes for those with the disorder.

Recent exploration of what matters for people with schizophrenia highlighted the need to feel safe, the opportunity for employment, access to good healthcare support and having meaningful social relationships.[[3]] These factors were very similar to findings of a local (unpublished) review of the long-term outcomes for people who have been through our anti-psychotic treatment trials.

The age of the institution may have passed but the messages emerging from work such as that of Sheree Gibb et al[[2]] might be that we still have a long way to go to deliver healthcare, social and occupational supports to people with schizophrenia that does not disadvantage them or stigmatise them.

There are good guidelines for the treatment of schizophrenia.[[4]] I suspect the problem is that we do not deliver according to these best evidence-guided recommendations.

The time between onset of symptoms and beginning treatment remains disappointingly high. We are used to strong pushes for the early identification of cancer because there is strong evidence that early detection and appropriate evidence-based interventions significantly alter the disease course. We do not see such initiatives for psychosis. An elegant Scandinavian study which was set up to examine differences with true early detection of psychosis showed that early treatment for first psychosis had positive effects on clinical and functional outcomes.[[5]]

Reasons for delay include the stigma attached to any diagnosis of a mental illness, and especially to that of schizophrenia. It is also well recognised[[6]] that the disorder itself causes a lack of awareness of the symptoms (anosognosia), such that an individual experiencing psychotic symptom will not have awareness of these. We have a long way to go the shift public attitude towards mental illness and to create safe environments where the young people experiencing their first episode of a psychotic disorder (illness onset is typically late adolescence to early adulthood) can present. They will often be reliant on family or close friends to assist them recognise a problem and seek help for it; thus the point of care needs to be user friendly for these support people also.

Though I do not have the data to support my clinical impression, it is likely that many presentations with schizophrenia are in crisis situations where there are concerns about the risk of the person with the disorder. They do not get seen in primary health settings, where one would ideally want an illness like this to be assessed and treated. By the time they present there is usually considerable disruption in their lives; relationships are challenged or disrupted; usual occupation or education and recreational pursuits have ceased. This loss of the usual social supports will coincide with a time of immense personal angst; the traumatic experience of identity dissolution, boundary loss and the like should not be underestimated. One only has to consider what it must be like to have some sinister voice that continues to berate you or threaten you; then, if you are brave enough to mention it to others, you then get told they cannot hear the voice—how do you assimilate that?

For my goal of dedicated public health campaigns that target early identification of and rapid interventions for those at risk of schizophrenia, it will be necessary to address the pervasive public prejudice and discrimination. This is no simple task and the available worldwide evidence of success for anti-stigma campaigns for mental illness is not reassuring.[[7,8]] Strategies are generally described as contact with consumers, education campaigns and social activism and protest. Both contact approaches and education campaigns do have small to medium effect sizes. There is no study of social activism approaches.

I am hopeful that dissemination of the costs of schizophrenia, both to the people who experience it and to the population as a whole, might stimulate people in influence to take the challenge to address the public health importance of reducing stigma, thereby enhancing the possibility of early access to best evidenced treatments.

Why we want to treat early and maintain good treatment is because it not only produces better outcomes regarding illness experience and function, but because it is also linked to arresting (and perhaps improving) loss of cortical matter[[9]] and decreasing the effect of schizophrenia on reducing life expectancy.[[10]] A German study[[11]] carefully reviewed the achievement of remission (using well defined criteria[[12]]) and suggests there is good reason for expectation of positive outcome from good treatment.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Wayne Miles: Clinical Director Research and Knowledge, Waitemata DHB; Clinical Associate Professor Department of Psychological Medicine, University of Auckland

Acknowledgements

Correspondence

Associate Prof Wayne Miles, Clinical Director Research and Knowledge, Waitemata DHB; Clinical Associate Professor Department of Psychological Medicine, University of Auckland

Correspondence Email

Wayne.miles@waitematadhb.govt.nz

Competing Interests

Nil.

1) Chong HY, Teoh SL, Wu DB-C, Kotirum S,Chiou C-F, Chaiyakunapruk N. Global economic burden of schizophrenia: a systematic review. Neuropsychiatric Diseases and Treatment. 2016; 12: 357-73.

2) Gibb S, Brewer N, Bowden N. Social impacts and costs of schizophrenia: a national cohort study using New Zealand linked administrative data. N Z Med J. 2021; 1537(134):66-83

3) Lloyd H, Lloyd J, Fitzpatrick R, Peters M. The role of life context and self-defined well-being in the outcomes that matter to people with a disagnosis of schizophrenia. Health Expectations. 2017; 20: 1061-72.

4) Galletly C, Castle D, Dark F, Humberstone V, Jablensky A, Killackey E, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Australian and New Zealand Journal of Psychiatry. 2016; 50 (5); 410-72.

5) Larsen TK, Melle I, Auestad B, Haahr U, Joa I, Johannessen O, et al. Early detection of psychosis: positive effects on 5-year outcome. Psychological Medicine. 2011; 41: 1461-69.

6) Pia L, Tamietto M. Unawareness in schizophrenia: Neuropsychological and neuroanatomical findings. Psychiatry and Clinical Neurosciences. 2006; 60: 531-7.

7) Corrigan PW, Morris SB, Michaels PJ, Rafacz JD, Rusch N. Challenging the public stigma of mental illness: a meta-analysis of outcome studies. Psychiatric Services. 2012; 63: 963-73.

8) Morgan AJ, Reavley NJ, Ross A, Too LS, Jorm AF. Intervetions to reduce stigma towards people with severe mental illness: Systematic review and meta-analysis. Journal of Psychiatric Research. 2018; 103:120-33.

9) van Haren NEM, Hulshoff Pol HE, Schnack HG, Cahn W, Mandl RCW, Collins DL, et al.Focal grey matter changes in schizophrenia across the course of the illness: a 5-year follow up study. Neuropsychopharmacology. 2007; 32: 2057-66.

10) Tiihonen J, Lonnqvist J, Wahlbeck K, Klaukka T, Niskanen L, Tanskanen A et al. 11 Year follow up of mortality in patients with schizophrenia: a population-based study (FIN11 study). The Lancet. 2009; 374:620-7.

11) Schennach R, Riedal M, Obermeir M, Jager, M, Schmauss M, Laux G et al.Remission and recovery and their predictors in schizophrenia spectrum disorders: Results from a 1 year follow-up naturalistic trial. Psychiatric Q. 2012; 83: 187-207.

12) Andreasen NC, Carpenter WT, Kane JM, Lasser RA, Marder SR, Weinberger DR, et al. Remission in schizophrenia: propsed criteria and rationale for consensus. American Journal of Psychiatry. 2005: 162: 441-9.

Contact diana@nzma.org.nz
for the PDF of this article

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