What is schizophrenia?

Schizophrenia is a long term mental illness. The disease is characterised by positive and negative symptoms. The positive symptoms are those such as hallucinations (seeing or hearing things that don’t exist) and delusions (strange fixed beliefs that are not true), while negative symptoms include lack of emotion, limited speech and an inability to enjoy any activities.

There are different types of schizophrenia, including:

  • Paranoid schizophrenia: Positive symptoms are severe (patients may hear many voices, see strange things, have many strange or disturbing beliefs)
  • Disorganised schizophrenia: Patients have disorganised speech and behaviour
  • Catatonic schizophrenia: Patients will have a movement disturbance, either being very active and restless or not moving at all for extended periods
  • Residual schizophrenia: Negative symptoms are severe with only mild positive symptoms

Statistics on schizophrenia

Schizophrenia affects about 1% of the general public. However, there is considerable variability between countries and even cities. In Australia, the prevalence of schizophrenia is around 1.5% of the population.

The onset of schizophrenia occurs around the late teens and early twenties for males, and the late twenties to mid-thirties for females. The incidence of schizophrenia is higher in males than females, migrants than native-born people, and urban regions than rural regions.

Risk factors for schizophrenia

Schizophrenia is a complex condition with many predisposing factors. These can be grouped into genetic, environmental and racial factors.

Genetic factors

Schizophrenia has a strong genetic component. If an individual’s parent or parents had schizophrenia, then that individual has a much higher risk of also developing schizophrenia. This does not just apply to parents; the more relatives have schizophrenia, the higher the risk of developing the condition.

Being male is also recognised as a predisposing factor for schizophrenia.

Environmental factors

Some of the environmental factors that have been associated with an increased risk of schizophrenia are:

  • Maternal smoking, diabetes, and rubella infection during pregnancy
  • Premature birth and low birth weight
  • Complications during birth that cause a baby to be without oxygen for some time
  • Lower socioeconomic status
  • Living in large cities
  • Stressful events in early childhood
  • Drug taking. Drugs such as amphetamines and cocaine have effects similar to the positive symptoms of schizophrenia. These drugs can also trigger schizophrenia. There is an increasing amount of evidence that cannabis damages the brain and can lead to schizophrenia. It is thought that cannabis doubles a person’s risk of schizophrenia.

Racial factors

The highest rates of schizophrenia are among African immigrants in the USA and UK. There are also higher rates in many other ethnic minority groups.

Progression of schizophrenia

Schizophrenia usually starts between the ages of 16 and 30. The condition tends to start earlier in men and later in women. There is usually a milder form of the condition first that includes depression, sleep changes, anxiety, poor concentration and social isolation. This early phase usually lasts 2 to 5 years. After this time, patients usually develop the positive symptoms (like hallucinations). This is often called the psychotic phase. Psychotic symptoms tend to occur in episodes of varying duration.

There are several ways that schizophrenia can then progress:

  • Episodes of psychotic symptoms with some residual symptoms in between (usually negative symptoms)
  • Episodes with no symptoms in between (the patient is healthy between episodes)
  • Continuous symptoms that do not change over time
  • Single episode with no ongoing symptoms
  • Single episode with some ongoing symptoms (these can include hearing just one voice, smelling something, poor self care, social isolation or other symptoms that occur much less than during the episode)

Symptoms of schizophrenia

Presentation is usually in the first episode of psychosis. During this time, the patient will have severe psychotic (positive) symptoms. This will include symptoms of:

  • Hallucinations: The patient will hear voices, see things that don’t exist, smell strange things, or even feel things (e.g. bugs crawling on their skin)
  • Delusions: These are false beliefs that the patient maintains despite being shown evidence that the belief is untrue. (E.g. patients believing that they are going to be killed, that the government is spying on them, that their thoughts are being stolen, or that a famous person is in love with them). There are many types of delusions that can involve love, persecution, wealth, self importance, mind control and many others.
  • Disorganised behaviour: The patient cannot do complex tasks because of a reduced ability to plan and carry out the task.

Patients often also have negative symptoms. These include:

  • Flat mood that doesn’t change or respond to others
  • Very limited speech
  • Poor self care
  • No motivation
  • No pleasure from activities that were once pleasurable
  • Withdrawal from social contact

Often negative symptoms have been present for a much longer period of time than the positive symptoms.


Clinical examination of schizophrenia

The clinical history of schizophrenia is best obtained from both the patient and a relative or close friend. Positive symptoms are best described by the patient, while negative symptoms are best described by a close relative or friend.

How is schizophrenia diagnosed?

The diagnosis is made on the clinical examination. There are no current diagnostic tests for schizophrenia. The doctor can do some tests to exclude other possible causes for the patient’s symptoms (e.g. alcohol withdrawal, drug abuse or infection), although these other causes are very uncommon.

Prognosis of schizophrenia

About 15% of schizophrenia patients will recover and not have ongoing symptoms; 70% will have ongoing symptoms; and 15% will have very severe symptoms and will not be able to function in society. The outcome varies considerably depending on the patient.

There are many things that influence the outcomes of schizophrenia. Outcomes are better if:

  • Symptoms start later in life
  • The patient is female
  • There are mainly positive symptoms
  • There are good social supports in place before diagnosis (especially being married)

Outcomes are worse if:

  • The condition starts early in life
  • The start of the symptoms is very gradual
  • The patient is male
  • Negative symptoms are severe
  • There is an extensive family history of schizophrenia
  • The patient is more socially withdrawn

Patients with schizophrenia are at very high risk of committing suicide. About 10% of patients with schizophrenia will kill themselves. About half of patients will consider, plan or attempt suicide. Those at highest risk of suicide are young males, especially those who also have drug abuse problems. Suicide is most common in the first few years after diagnosis.

How is schizophrenia treated?

Treatment includes medications, electroconvulsive therapy and psychotherapy.

Medication

Medication is the main treatment for schizophrenia and has good results if the patient continues to regularly take the medication (many schizophrenic patients do not regularly take medication). This is termed medication compliance.

The main drugs that are used are the second generation antipsychotics (also known as atypical antipsychotics). These drugs are the best treatment for both acute psychosis and long term management. They are the first treatment used in patients with schizophrenia.

Other medications that are used include clozapine, first generation antipsychotics (typical antipsychotics) and benzodiazepines. These medications often don’t work immediately. It is important to give a medication a trial of 4-6 weeks at an adequate dose before deciding if it works or not.

Second generation anti-psychotics (atypical anti-psychotics)

These drugs are the mainstay of treatment. They have two important advantages over early first generation drugs. Firstly, they are effective at reducing negative symptoms, and secondly, these drugs do not cause extrapyramidal side effects (including tremor, slurred speech and dystonia) or Parkinson-like symptoms.

The main drugs in this class are:

All the drugs cause some degree of weight gain as a major side effect. Other side effects are:

  • Risperidone: Low blood pressure, sexual dysfunction, extrapyramidal side effects at high doses
  • Paliperidone: similar to risperidone including low blood pressure, fast pulse rate, nausea, headache, extrapyramidal side effects at high doses, changes to breast tissue, and high blood sugar in some people.
  • Olanzapine: Extra weight gain, diabetes, sleepiness
  • Quetiapine: Low blood pressure, sleepiness

These drugs reduce the risk of a patient having a psychotic episode by one third. They can also reduce the risk of suicide.

Risperidone

There are two main ways that a person can take risperidone, orally (Risperdal Oral) and through injection (Risperdal Consta). Risperdal Oral needs to be taken every day and is available as tablets, pleasant tasting quick dissolve tablets and in syrup form. Risperdal Consta is injected into the person’s buttock once every two weeks. The main benefit of injection is that the person doesn’t have to worry about taking the medication every day.

Risperdal Consta is a good alternative to daily medication if the person is finding it difficult to remember to take their medication every day. It is recommended that Risperdal Consta only be started after the person has been on daily Risperdal for some time, and is both feeling better and not experiencing any serious side effects. The main side effects of Risperdal Consta are similar to the side effects of the tablet and syrup forms, and include low blood pressure, headache, dizziness and extrapyramidal side effects. Some people who take Risperdal Consta experience sleepiness. Although sleepiness is the most common reason for stopping treatment, studies have shown that only about 7% of patients will have significant or ongoing sleepiness. Only 1.5% of patients needed to stop treatment for this reason.

Paliperidone

Paliperidone is the substance created when risperidone is ingested into the body. It has been prepared as a prolonged release tablet to stabalise levels in the blood and allow once daily dosing. This drug is mostly excreted by the kidneys so it provides a good alternative for those with liver disease however those with kidney problems may experience increased side effects.

It is important that patients swallow the tablet whole and do not break, crush or chew it. It should be taken every morning at the same time relative to food. Don’t be alarmed if you see the tablet in your faeces, this is just the outside capsule, the medication will have been absorbed into your body.

Clozapine

Clozapine is also an atypical antipsychotic, but is more powerful and is used in schizophrenia that does not improve with other medication. The drug reduces both positive and negative symptoms of schizophrenia. The main side effects are a reduction in white blood cells, weight gain, sedation and constipation. The reduction in white blood cells can cause serious infection. As a result, any patient on clozapine has regular blood tests performed by their doctor.

First generation anti-psychotics (typical antipsychotics)

These older drugs are still sometimes used. Chlorpromazine works well at both controlling symptoms and increasing functioning. Side effects are wide-ranging and include sleepiness, jerky movements, weight gain and dizziness. This medication is now only occasionally used for schizophrenia.

Haloperidol (Serenace) is another first generation antipsychotic. It is only used to help calm an agitated or violent patient. The drug is usually given as an injection.

Benzodiazepines

Benzodiazepines are sometimes also used in schizophrenia. However, recent evidence concludes that benzodiazepines should only be used to help a patient calm down if they are having a severe psychotic episode.

Early intervention

Treatment should be started as soon as possible. This is for a number of reasons. Firstly, patients are in considerable distress when they are experiencing positive symptoms and may become violent or self-harming. Secondly, evidence shows that the longer a patient is without treatment, the longer it will take for the patient to get better once the treatment is started. Thirdly, symptoms (especially negative ones) worsen over the course of the condition if left untreated. And lastly, schizophrenia is always associated with considerable social isolation that worsens if left untreated.

Medication compliance

Medication compliance is critical to the optimal management of disease, and is of particular importance for patients with schizophrenia. Several studies investigating the outcomes of non-compliance have shown that patients with schizophrenia who do not take their medication as regularly as prescribed have higher rates of relapse, hospital admission and suicide as well as increased mortality.

A recent review of scientific literature found that while medication non-adherance rates varied, non-adherance was as high as 89%. When adherence was strictly measured, defined as “taking medication as prescribed at least 75% of the time,” the mean non-adherence rate was 49.5%. A large percentage of patients with schizophrenia (36%) have been shown to discontinue their prescribed medication within 30 days of their first hospitalisation. For those discontinuing medication there was a 10-fold increase in mortality.

In a separate study, if atypical antipsychotic medication was interrupted for greater than a 30 day period, the rate of suicide was almost four times greater compared to those with no interruption.

Reasons for non-compliance vary. However, those at most risk for non-compliance include patients who are early in the disease progression, do not recognise their disease state, have disorganised thinking, substance abuse, a negative view of medication, history of relapse/rehospitalisation, infrequent outpatient clinical contact, previous non-adherence and those with poor planning at discharge from the hospital.

By addressing risk factors for non-compliance the long term outcomes of schizophrenic patients can be improved with fewer relapses and decreased rates of hospitalisation, suicide and mortality. Compliance could further be increased by improved patient education, minimisation of side effects and the use of simple dosing schedules including the use of long acting injectible antipsychotics like Risperdal Consta.

 

Patient who does not want to take their medication

Medication Adherence Rating Scale
(MARS)

How closely you adhere to your medication plan affects the progression and outcome of your psychosis. The Medication Adherence Rating Scale (MARS) is a self-report measure of medication adherence in psychosis. Use the MARS tool to determine your willingness and ability to take oral medication every day.

Yes No
1. Do you ever forget to take your medication?
2. Are you careless at times about taking your medicine?
3. When you feel better, do you sometimes stop taking your medicine?
4. Sometimes if you feel worse when you take the medicine, do you stop taking it?
5. I take my medication only when I am sick.
6. It is unnatural for my mind and body to be controlled by medication.
7. My thoughts are clearer on medication.
8. By staying on medication, I can prevent getting sick.
9. I feel weird, like a ´zombie´, on medication.
10. Medication makes me feel tired and sluggish.

Results

This individual has scored  out of 10 on the adherence rating scale.

It is likely they are adhering to their schizophrenia medication.

This individual has scored  out of 10 on the adherence rating scale.
They are not adhering to the prescribed medication schedule.

References:

  1. Thompson K et al. Schizophrenia Research 2000;42:241-7.
  2. Fialko L, et al. Schizophrenia Research 2008;100:53-9.

This information will be collected for educational purposes, however it will remain anonymous.

 

Electroconvulsive therapy

Electroconvolusive therapy involves putting a patient to sleep and then applying a small, controlled amount of electricity to the head. This is considered for patients whose symptoms are not controlled by clozapine and who have severe psychotic symptoms or severe movement disorganisation (e.g. they are extremely agitated and restless), or are planning suicide attempts.

Psychotherapy

Psychotherapy is extremely important in the long term treatment of schizophrenia. The benefits of psychotherapy include improved taking of medication, better control of negative symptoms, and reduced social isolation. The result is an overall better outcome for the patient. The types of psychotherapy used are discussed below.

Social skills training

A specialised social skills training program aimed at reducing social withdrawal by focusing on conversational skills and interpersonal relationships.

Cognitive-behavioural therapy

Cognitive-behavioural therapy challenges delusions with the hope of allowing the patient to overcome false beliefs.

Drug abuse programs

Programs to stop any co-occurring substance abuse.

Family therapy

Family therapy is a form of psychosocial therapy that was developed because of the observation that schizophrenic patients from families with high levels of criticism, hostility, or over involvement, have increased rates of relapses compared to patients from families that tend to be less emotionally expressive. Family therapy aims to:

  • Construct an alliance with relatives who care for the patients;
  • Reduce adverse family atmospheres;
  • Enhance the capacity of relatives to anticipate and solve problems;
  • Reduce anger and guilt expressed by the family;
  • Set realistic expectations of patient performance;
  • Encourage appropriate limits; and
  • Attain desirable behavioural changes in relatives of the patient.

In recent scientific studies family therapy was shown to improve the clinical course of the disease and increase the number of patients regularly taking their medication. However, it should be noted that these interventions are proposed as adjuncts rather than alternatives to drug treatments.

The benefits of family intervention are many and include significant reductions in hospital admission, fewer relapses and as discussed previously an increase the number of patients regularly taking their medication. General social functioning was also improved with family intervention, which was shown to increase the families’ understanding of the patients needs and increase overall quality of life.

Family therapy For more information, see Family Therapy (Family Focus Therapy).

 

Supported employment

Part of the multidisciplinary approach to treating schizophrenia involves supporting those living resources that many schizophrenic patients find difficult to maintain and not just treating the symptoms of the illness. This includes employment. Gainful employment has the potential to enhance economic independence, self esteem and adaption into the community. While most patients with schizophrenia report that they want to work, only 10-20% are employed.

Previous methods to enhance employment rates include the train-and-place models of vocational rehabilitation, however, these have not proven to be particularly successful. Rather supported employment programs which involve a place-then-train philosophy have become more favourable. In these programs training takes place on the job with a job coach. Individuals are placed according to their interests and strengths and receive ongoing support from a collaborative team. Several scientific studies have shown that individuals who participate in the place-then-train supported employment programs are more likely to gain employment and earn more money than those who undertake traditional vocational rehabilitation.

For ongoing success, both methods need to overcome issues related to retention of employment. Factors that have been shown to influence job retention include the presence of negative symptoms, recent hospitalisation, cognitive deficits and persistent psychotic symptoms. Hence a multidisciplinary approach that supports living resources as well as optimal medical management may lead to improved outcomes for patients with schizophrenia.

Supported housing

SchizophreniaIt is generally well accepted that patients with schizophrenia have a reduced ability to maintain living resources such as quality housing and employment. Hence as part of a multidisciplinary approach in the treatment of schizophrenia, health providers need to assess these living resources and not just the symptoms of the illness.

International studies have shown that if patients with schizophrenia, and consumers in general, live in good quality housing, they have significantly improved mental health. This stems from improved quality of life, decreased medication requirements, decreased readmission rates and improved self reports of mental health/wellness.

For many patients with schizophrenia, independent living in their own home is an important part of their recovery. An American study categorised 85 patients with schizophrenia based on their dwelling status: those living in residential settings and those living independently. For those patients living independently, they had fewer symptoms, increased motivation and better level of functioning.

In an Australian study investigating the experience of people attending mental health services and living with a psychotic disorder 45% were either accommodated in institutions, hostels, group homes, other supported housing, crisis care shelters or homeless within a month of being interviewed. These patients represent a group with special needs, for whom addressing their housing situation has the potential to significantly improve the clinical course of their disease and social adjustment.

The effect of housing on the clinical course of schizophrenia is illustrated by a study investigating the course and consequences of patients admitted to an acute care facility in central Sydney. The authors identified poor quality housing as a key determinant for high rates of readmission. Unfortunately, many services do not consider suitable long-term housing options as their services are exhausted trying to find short-term and crisis accommodation.

The lack of quality housing for patients with schizophrenia is a concern as it is associated with increased symptoms, increased hospitalisation rates and reduced quality of life. While Australian state and federal governments acknowledge housing as a critical element in the provision of services to patients with schizophrenia, the issue of suitable housing is only now beginning to be addressed.

More information

Schizophrenia
For more information on schizophrenia and its treatments, and some useful tools, animations and videos, see
Schizophrenia.

Schizophrenia references

  1. Lehman AF, Lieberman JA, Dixon LB, et al. Practice guideline for the treatment of patients with schizophrenia, second edition. Am J Psychiatry. 2004;161(2 Suppl):1-56. [Abstract]
  2. McGrath JJ. Myths and plain truths about schizophrenia epidemiology: The NAPE lecture 2004. Acta Psychiatr Scand. 2005;111(1):4-11. [Abstract]
  3. The Florey Institute of Neuroscience and Mental Health. Schizophrenia [online]. Parkville, Vic: 2008 (cited 17 June 2008). Available from: [URL link]
  4. Mental Illness Fellowship of Australia Inc. Understanding schizophrenia [online].  2004 (cited 17 June 2008). Available from: [URL link]
  5. McGrath J, Saha S, Welham J, et al. A systematic review of the incidence of schizophrenia: The distribution of rates and the influence of sex, urbanicity, migrant status and methodology. BMC Med. 2004;2:13. [Full text]
  6. Mueser KT, McGurk SR. Schizophrenia. Lancet. 2004;363(9426):2063-72. [Abstract]
  7. Schultz SH, North SW, Shields CG. Schizophrenia: A review. Am Fam Physician. 2007;75(12):1821-9. [Full text]
  8. Di Forti M, Lappin JM, Murray RM. Risk factors for schizophrenia: All roads lead to dopamine. Eur Neuropsychopharmacol. 2007;17(Suppl 2):S101-7. [Abstract]
  9. Bellon A. New genes associated with schizophrenia in neurite formation: A review of cell culture experiments. Mol Psychiatry. 2007;12(7):620-9. [Full text]
  10. Van Os J. Is the party over? Evidence that cannabis is a causal risk factor for schizophrenia. 2007; S21: S345.
  11. Diagnostic and Statistical Manual of Mental Disorders (4th edition). Washington, DC: American Psychiatric Association; 2000.
  12. Bolton C, Gooding P, Kapur N, et al. Developing psychological perspectives of suicidal behaviour and risk in people with a diagnosis of schizophrenia: We know they kill themselves but do we understand why? Clin Psychol Rev. 2007;27(4):511-36. [Abstract]
  13. Risperdal [online]. 2008 [cited 12 January 2008]. Available from: [URL link]
  14. Thompson PM, Vidal C, Giedd JN, et al. Mapping adolescent brain change reveals dynamic wave of accelerated gray matter loss in very early-onset schizophrenia. Proc Natl Acad Sci USA. 2001;98(20):11650-5. [Full text]
  15. Risperdal Consta side effects [online]. Drugs. 2007 [cited 12 January 2008]. Available from: [URL link]
  16. Mackay FJ, Wilton LV, Pearce GL, et al. The safety of risperidone: A post marketing study of 7684 patients. Human Psychopharmacol Clin Exp. 1998;13(6):413-8. [Abstract]
  17. National Prescribing Service. Paliperidone (Invega) for schizophrenia [online]. Sydney: NPS MedicineWise; 2008 [cited 31 January 2009]. Available from: [URL link]
  18. Picchioni MM, Murray RM. Schizophrenia. BMJ. 2007;335(7610):91-5. [Full text]
  19. Adams CE, Awad G, Rathbone J, et al. Chlorpromazine versus placebo for schizophrenia. Cochrane Database Syst Rev. 2007;(2):CD000284. [Full text]
  20. Volz A, Khorsand V, Gillies D, et al. Benzodiazepines for schizophrenia. Cochrane Database Syst Rev. 2007;(1):CD006391. [Full text]
  21. Bellack AS. Skills training for people with severe mental illness. Psychiatr Rehabil J. 2004;27(4):375-91. [Abstract]
  22. Kopelowicz A, Liberman RP, Zarate R. Recent advances in social skills training for schizophrenia. Schizophr Bull. 2006;32(Suppl 1):S12-23. [Full text]
  23. Pharoah F, Mari J, Rathbone J, et al. Family intervention for schizophrenia. Cochrane Database Syst Rev. 2006;(4):CD000088. [Full text]
  24. Bressi C, Manenti S, Frongia P, et al. Systemic family therapy in schizophrenia: A randomized clinical trial of effectiveness. Psychother Psychosom. 2008;77(1):43-9. [Abstract]
  25. Browne G, Courtney M. Schizophrenia housing and supportive relationships. Int J Ment Health Nurs. 2007;16(2):73-80. [Abstract]
  26. Gupta S, Steinmeyer C, Frank B, et al. Older patients with schizophrenia: Nature of dwelling status and symptom severity. Am J Psychiatry. 2003;160(2):383-4. [Full text]
  27. Jablensky A, McGrath J, Herrman H, et al. People living with psychotic illness: An Australian study 1997-98. Commonwealth of Australia; 1999. Available from: [URL link]
  28. Berger J, Bashir M, Armitage P, et al. Acute care for people with schizophrenia living in the central Sydney area. Sydney: NSW Department of Health; 1997.
  29. Lacro JP, Dunn LB, Dolder CR, et al. Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: A comprehensive review of recent literature. J Clin Psychiatry. 2002;63(10):892-909. [Abstract]
  30. Tiihonen J, Wahlbeck K, Lönnqvist J, et al. Effectiveness of antipsychotic treatments in a nationwide cohort of patients in community care after first hospitalisation due to schizophrenia and schizoaffective disorder: Observational follow-up study. BMJ. 2006;333(7561):224. [Full text]
  31. Herings RM, Erkens JA. Increased suicide attempt rate among patients interrupting use of atypical antipsychotics. Pharmacoepidemiol Drug Saf. 2003;12(5):423-4. [Abstract]
  32. Weiden PJ, Kozma C, Grogg A, et al. Partial compliance and risk of rehospitalization among California Medicaid patients with schizophrenia. Psychiatr Serv. 2004;55(8):886-91. [Full text]
  33. Lacro JP, Dunn LB, Dolder CR, et al. Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: A comprehensive review of recent literature. J Clin Psychiatry. 2002;63(10):892-909. [Abstract]
  34. Weiden P, Zygmunt A. The road back: Working with the severely mentally ill. J Pract Psychiatr Behav Health. 1997;3:106-10.
  35. Ayuso-Gutiérrez JL, del Rio Vega J. Factors influencing relapse in the long-term course of schizophrenia. Schizophr Res. 1997; 28(2-3): 199-206. [Abstract]
  36. Csernansky  JG, Mahmoud R, Brenner R. A comparison of risperidone and haloperidol for the prevention of relapse in patients with schizophrenia. N Engl J Med. 2002;346(1):16-22. [Full text]
  37. Lam YW, Velligan DL, Ereshefsky L, et al. Intra-individual variability in plasma concentrations as an indicator of adherence in schizophrenia. Poster presented at the 42nd Annual New Clinical Drug Evaluation Unit (NCDEU) Meeting. Boca Raton, FL: 10-13 June 2002.
  38. Davis JM, Metalon L, Watanabe MD, et al. Depot antipsychotic drugs: Place in therapy. Drugs.1994;47(5):741-73. [Abstract]
  39. Mentschel CC, Leucht SM, Kane JM. Depot-drugs may reduce relapses in schizophrenic outpatients: A meta-analysis [Abstr. NR191]. 156th Annual Meeting of the American Psychiatric Association (APA). San Francisco: 17-22 May 2003.
  40. Adams C, Fenton MKP, Quraishi S, et al. Systematic meta-review of depot antipsychotic drugs for people with schizophrenia. Br J Psychiatry. 2001;179:290-9. [Full text]
  41. Walburn J, Gray R, Gournay K, et al. Systematic review of patient and nurse attitudes to depot antipsychotic medications. Br J Psychiatry. 2001;179:300-7. [Full text]
  42. Moller HJ, Llorca PM, Sacchetti E, et al. Efficacy and safety of direct transition to risperidone long-acting injectable in patients treated with various antipsychotic therapies. Int Clin Psychopharmacol. 2005;20(3):121-30. [Abstract]
  43. Kissling W, Heres S, Lloyd K, et al. Direct transition to long-acting risperidone: Analysis of long term efficacy. J Psychopharmacol. 2005;19(5 Suppl):15-21. [Abstract]
  44. Browne G, Courtney M. Schizophrenia housing and supportive relationships. Int J Ment Health Nurs. 2007;16(2):73-80. [Abstract]
  45. Lehman AF, Goldberg R, Dixon LB, et al. Improving employment outcomes for persons with severe mental illnesses. Arch Gen Psychiatry. 2002;59(2):165-72. [Full text]
  46. Twamley EW, Jeste DV, Lehman AF. Vocational rehabilitation in schizophrenia and other psychotic disorders: A literature review and meta-analysis of randomized controlled trials. J Nerv Ment Dis. 2003;191(8):515-23. [Abstract]
  47. McGurk SR, Mueser KT. Cognitive functioning, symptoms, and work in supported employment: A review and heuristic model. Schizophr Res. 2004;70(2-3):147-73. [Abstract]
  48. Velligan DI, Gonzalea JM. Rehabilitation and recovery in schizophrenia. Psychiatr Clin North Am. 2007;30(3):535-48. [Abstract]
  49. Drake R, McHugo G, Bebout R, et al. A randomized clinical trial of supported employment for inner-city patients with severe mental disorders. Arch Gen Psychiatry. 1999;56(7):627-33. [Full text]
  50. Bond G, Dietzen L, McGrew J, et al. Accelerating entry into supported employment for persons with severe psychiatric disabilities. Rehab Psych. 1995;40(2):91-111. [Abstract]
  51. Cook JA, Lehman AF, Drake R, et al. Integration of psychiatric and vocational services: A multisite randomized, controlled trial of supported employment. Am J Psychiatry. 2005;162(10):1948-56. [Abstract]
  52. Razzano LA, Cook JA, Burke-Miller JK, et al. Clinical factors associated with employment among people with severe mental illness. J Nerv Ment Dis. 2005;193(11):705-13. [Abstract]