Beyond the Cuckoo's Nest ... coping with schizophrenia

One New Zealander in 100 will suffer from schizophrenia. RON TAYLOR looks behind the lurid court cases at a greatly misunderstood illness.

The news report is all too familiar: a 23-year-old from Masterton charged with murdering his 2-year-old cousin and attempting to murder the dead boy's 3-year-old sister.

In court his lawyer relates how, several months before the slaying, the accused talked about seeing a faceless devil in a long black coat, of having conversations with Satan, of saying he could "feel a bad, evil thing flowing out of him."

At other times he sat silent and smirked, lost in his inmost thoughts.

Yet he had had a loving family upbringing and had been a keen sportsman and champion boxer.

The quietest and most placid of her children, according to his mother, he was profoundly affected by his father's death and his depression was compounded when he found his employer fatally injured after a work accident.

His behaviour deteriorated rapidly and he was diagnosed with schizophrenia.

Medically, his condition was stabilised and he was deemed fit to stay with family provided he took his anti-psychotic medication, Risperidone.

That is the nub of the defence and an expected plea of not guilty on the grounds of insanity.

The upshot of the tragedy is public perception of yet another failure by mental health services - of a dangerous psychotic left to roam the streets although he could have been controlled by easy-to-take medication. In fact, this is an oversimplification and far from reality.

What is schizophrenia?

The Concise Oxford defines it as "a mental disease marked by a breakdown in the relation between thoughts, feelings and actions, frequently accompanied by delusions and retreat from social life."

It has two important features.

First, no known medication can "cure" schizophrenia in the lay sense of the word.

Second, most schizophrenics are sensitive and withdrawn and tend to hurt themselves rather than others.

"There's more likelihood of your being assaulted and in danger from a drunk coming out of a bar than by somebody who has schizophrenia," says psychiatrist Dr Allen Fraser, director of the Mood Disorder Service of Waitemata Health and a branch committee member of the Royal Australian and New Zealand College of Psychiatrists.

"Schizophrenia does not necessarily cause severe deterioration in function. There are some people who have episodes of acute psychosis and recover completely after each episode.

"That is one extreme. The other is severe disorder of the brain which leads to progressive brain dysfunction ... Every individual is different, as is their medication and tolerance to it."

It is estimated that one New Zealander in 100 will experience schizophrenia at some stage. That is about 38,000 people.

It affects all races and levels of society, although younger people are more vulnerable, particularly young men, and an attack can be triggered by alcohol or drug abuse such as smoking cannabis.

Dr Fraser says that if somebody has a very supportive environment and the psychosis is not associated with personality disturbance and aggression, he or she may well live for a long time without being diagnosed.

Do many schizophrenics need institutional care?

A new development is the number of patients in their 50s and 60s needing long-term care after years in the community.

"They've been looked after by parents who have become too old to cope. This is going to continue to be a difficulty because these people aren't capable of living independently and our society is going to have to grapple with how to care for them," Dr Fraser says.

"Up to about 20 years ago, these people would have gone into a psychiatric hospital, but we don't have them any more.

"Added to that, these people's life expectancy, with good-quality care, is now much the same as the general populace."

How may schizophrenia affect you?

Dr Fraser says schizophrenia affects a multitude of brain functions such as perception, emotional expression and attitude to goals.

Many of those diagnosed may not have another episode for years, then there is a recurrence. More fortunate patients may have one or two episodes and then never have another.

What about medication?

For most sufferers, symptoms can be alleviated by the use of medication and good support from family, friends and the mental health services.

The introduction of new anti-psychotic drugs known as atypicals, as distinct from those labelled traditional drugs, has been a major advance.

The first was Clozapine in the 1960s, still regarded as the gold standard because it has the best scientific record of effectiveness. Others in use are Risperidone and Olanzapine.

All are subsidised by the Government drug-buying agency, Pharmac, which has just approved one of the latest products on the international market, Seroquel (quetiapine fumarate).

It is said to be effective for patients who have not fully responded to treatment.

Dr Fraser believes all medications which have been shown to be effective should be available.

"Every psychiatrist knows of patients unable to satisfactorily tolerate one product or another. The more medications the better, and the more likely we'll find one that a patient can tolerate and improve on."

He says the new drugs are very expensive and Pharmac is cost conscious.

"But we [psychiatrists] have been reasonably happy with the way Pharmac's put restrictions on the anti-psychotics.

"They have acknowledged that there may be a case for choosing different anti-psychotics and they've made them relatively available."

Is medicine alone enough?

Dr Tony Fernando, who is a senior lecturer in psychiatry at the University of Auckland Medical School and an adviser to the Schizophrenia Fellowship in Auckland, says medication is only one piece in a patient's management.

Many factors can trigger negative or violent reactions, including a patient's perception of the treatment.

"For example, it is quite possible for a patient's delusion to lead him to believe that his medication is rubbish, it is a medication from hell, Satan's work, even if it is the best we can prescribe," says Dr Fernando.

"The patient may believe someone is giving him medication to control his brain or - and this has nothing to do with medication - he might believe, 'I'm the one who's well, all of you are sick. You're the ones who need the medication'."

Dr Fernando says it can be very difficult to persuade some patients otherwise and to take their medication.

"There is no medication which doesn't have some side-effects such as weight gain, sexual dysfunction and drowsiness. The atypicals can only be administered in pill form or as syrup, which makes them easy for a patient to spit out."

Work is being done on some atypicals so they can be administered by injection, and this will be very helpful in dealing with patients who are not cooperative.

Dr Fernando adds that the great majority of patients do cooperate and take their medication.

What sort of things can affect a schizophrenic patient?

Dr Fernando says the environment in which a patient lives is critical. That is why it is of prime importance to involve family, partners and friends in treatment.

However, while many provide very good care and support, inevitably there are families where life is always stressful.

Location is another factor. Patients with a psychosis and living in a small rural centre may not have the same access to specialist care as people in big cities.

Then again, life in smaller communities is generally less stressful than in a city. A patient with schizophrenia can be very sensitive to the noise and stimulation of city life.

"They can be affected by information overload - for example, traffic noise. A normal person's brain dampens down the noise. But for some with schizophrenia, all the stimulus bombards them and their brain can't pick and choose what to focus on and what to dampen down ... It's like hearing voices inside their head. They can be quite tormented."

As Dr Fernando speaks, a helicopter lands in the grounds of Auckland Hospital.

"If you have a psychosis and you're paranoid and you hear that, you may think, 'Gosh, they're coming to get me.' Some people can really believe that."

How effective is treatment these days?

"For now there is no cure, but many of our young patients who have optimum treatment - meaning really good medication, good family support and lots of education and psychological work - are living very normal lives," says Dr Fernando.

"We have this image that the patient with schizophrenia is the bum in the street, hearing voices, picking up rubbish and homicidal.

"That is not correct. In many of our patients, particularly the younger ones, you wouldn't even know that they have an illness. A lot of them are working full time or at university. Some of them are doing both.

"In the past 20 years treatment has improved phenomenally compared with that portrayed in the classic movie One Flew Over the Cuckoo's Nest, which unfortunately still influences public perception of schizophrenia. Only by education will we change that ... show that such a tormenting illness can be contained, that patients can have a quality life."