Schizophrenia has been called “the worst disease affecting mankind” (1). It is a complex neuropsychiatric disorder, with multiple clinical features. These include cognitive impairment and deficits, mood symptoms, and psychiatric symptoms (hallucinations and delusions). It is also arguably the diagnosis that carries the greatest degree of stigma.
For many years, schizophrenia was untreatable, until the discovery of antipsychotic medications in the 1950s. These first-generation antipsychotic medications offered hope, but many people were left with either a lack of efficacy or intolerable side effects. Today, thanks to the newer second-generation antipsychotic medications, and clozapine for treatment-resistance, the odds for recovery from schizophrenia are possible for many.
The absence of insight is one of the most serious symptoms that prevents an individual with schizophrenia from receiving treatment. A lack of insight is called anosognosia. It is common in schizophrenia and other serious mental illness. It is more than denial, it is a firm and false belief that the affected individual is not sick and does not need medical treatment. Many people with schizophrenia develop delusions and believe things a mentally healthy person would find absurd. In the movie, A Beautiful Mind, while struggling with schizophrenia, Nobel Prize-winning mathematician John Nash believes that a microchip has been inserted in his body by the FBI because he is on a special mission.
When a person begins their journey on a downward spiral into schizophrenia, especially untreated schizophrenia, the following are some consequences:
Individuals become tortured with delusions and hallucinations
Symptoms of schizophrenia can undermine a person’s life and can take away what matters most, such as a college education, pursuing a career, establishing relationships, buying a house, and raising a family. A person with schizophrenia often neglects personal hygiene and becomes malodorous. Many live in fear of the hallucinations raging inside their minds and feel detached from reality. Despite this, many will never seek out treatment until they are involuntarily hospitalized, which state laws allow. Psychiatric hospitalizations, which can often be avoided with early intervention, can be very costly ($1500 to $3000 a day depending on the location.
Families are fractured
Families of individuals struggling with schizophrenia often wonder what they did wrong, though schizophrenia is a genetic disorder, and no one is at fault. Parents may feel burdened by the many hours of care they have to provide, traveling to doctors’ appointments, researching how to best help their loved one, and having long and frustrating conversations to try and convince him or her they need treatment. Some parents who refuse to allow a delusional, violent, and unpredictable son or daughter to live in their home are struck by guilt, wondering if they did the right thing.
Hundreds of billions of dollars annually in cost to society
Schizophrenia incurs high direct and indirect costs to society that are expensive. Multiple hospitalizations, a lifetime of regular outpatient visits, legal costs (arrests, court hearings, re-incarceration due to a relapse) and lifetime disability (payments for room and board) add up to a huge cost. But, notably, if a person is identified earlier, they will have a better outcome. Full adherence to antipsychotic medication can prevent relapse (similar to full adherence to insulin in people with diabetes), and many who stick to their treatment plan may regain healthy minds return to their baseline, and contribute to society.
Homelessness and substance use
Untreated schizophrenia may lead to self-medicating with illicit substances, which can cause recurrence of psychosis and sabotage recovery. It is a daunting task to care for persons with schizophrenia who are addicted to substances. Many will become homeless, with cognition too impaired to hold even a simple job. People with schizophrenia are vastly overrepresented in the homeless community (2).
The legal and prison systems
When deinstitutionalization began in the '60s, funding and programs for those with developmental disabilities such as autism and Down’s Syndrome were made available. However, people with schizophrenia were not adequately covered by health insurance, often ending up on the streets, or in jail for crimes stemming from abnormal behavior triggered by the illness. Today, people with schizophrenia are also vastly overrepresented in jails and prisons (3).
The pharmaceutical industry
Hundreds of millions of dollars have been spent to search for a cure for schizophrenia, or at least better medication options with greater efficacy and fewer side effects than first-generation antipsychotics. Clozapine was approved by the FDA in 1989 and remains the antipsychotic drug with the highest efficacy after several decades, although it can have several safety and tolerability issues. Research continues with the hope that future medications will not only address the psychotic symptoms of schizophrenia, such as hallucinations and delusions, but also cognitive deficits (in memory, attention, or decision-making) and negative symptoms such as apathy, lack of motivation, inability to socialize, anhedonia, and blunted facial expression. Though a few medications are in the pipeline, their efficacy will not be known until the controlled clinical trials are completed and examined by the FDA for possible approval (4,5).
The effects of suicide
There is a very high suicide rate in people with schizophrenia. The rate of suicide in persons with schizophrenia is 4 to 13 percent (6). Studies report up to 10,000 percent higher death rates from suicide in young people with schizophrenia compared with the same age group in the general population (7). This is tragic for young people just starting their lives and is difficult to prevent. There is hope that the recent initiation of the 988 crisis hotline will offer more people struggling with suicide much-needed support (8).
There is hope
Despite the devastating impacts of schizophrenia, there is hope. Today, many people with ongoing treatment for schizophrenia (usually by committing to taking antipsychotic medication for life) reclaim their lives, work, attend college, and enjoy meaningful relationships again. Persons affected by schizophrenia can achieve remission by avoiding any further psychotic relapses after the initial hospitalization with uninterrupted adherence made possible through long-acting injectable antipsychotics (with no need for pills) that can be given once every one to six months. Unfortunately, the vast majority of persons with schizophrenia who improve significantly during their first hospitalization are discharged on pills, which they often do not take regularly, leading to multiple relapses that can destroy more brain cells and render the person disabled.
Prompt and efficacious treatment with 100 percent adherence to antipsychotic medications can heal people with schizophrenia, enable them to return to their baseline functioning (like school or work) and bring families back together again. This will also avoid rehospitalization, re-incarceration, suicide, homelessness, and exorbitant costs to society. Recovery from schizophrenia is a win-win for patients, their families, and society.
Co-authored by Henry A. Nasrallah, M.D., Professor of Psychiatry, Neurology, & Neuroscience, University of Cincinnati College of Medicine
References
(1) Editorial: Where next with psychiatric illness? Nature 1988; 336:95-96.
(2) Folsam, D. Schizophrenia in homeless persons: a systematic review of the literature. Acta Psychiatr Scand. 2002 Jun;105(6):404-13. https://pubmed.ncbi.nlm.nih.gov/12059843/
(3) Weill Cornell Medicine. Fact Sheet: Incarceration and Mental Health. Retrieved January 27, 2024.
(4) Karuna Therapeutics. KarXT https://karunatx.com/pipeline-programs/karxt/ . Retrieved January 27, 2024.
(5) Ralmitaront. https://en.wikipedia.org/wiki/Ralmitaront Retrieveid January 27, 2024.
(6) Sher, Leo et al. Suicide in Schizophrenia: An educational overview. Medicina (Kaunas). 2019 Jul; 55(7): 361.
(7) Zaheer J et al: Schizophrenia Research 222:282-38, 2020.
(8) Yeiser, Bethany. Is 988 Different From 911? Retrieved January 27, 2024.
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