Schizophrenia is a serious mental health problem that affects thinking, feeling and behaviour. It is most likely to start between the ages of 15 to 35 (although it can occur at any age) and will affect about 1 in every 100-200 people during their lifetime.

Schizophrenia is a complex condition, and symptoms can vary a lot between different people. In fact, everyone's symptoms will be unique. The number of people in the population with schizophrenia is around 1 per 100-200 people. That number seems to be roughly the same in different countries, although it can vary a bit. This is different to e.g. heart disease and cancers, which can vary wildly. The rate is the same in males and females, although the symptoms tend to appear slightly earlier in males (mean 15-30 years) than in females (peak 20-35 years).  

The word schizophrenia is often misunderstood. It is NOT a split or multiple personality, it is not the result of bad parenting or childhood trauma and does not mean the person is violent (which can somtimes happen but is the exception rather than the rule). Having to go into hospital is often not needed and many people with schizophrenia live a stable life, work, and have relationships.

Please read further information on psychosis for one of the main symptoms of schizophrenia.

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Schizophrenia probably starts gradually over several years, and there may be changes to the structure of the brain. It seems that the sooner someone with schizophrenia gets treatment the better.

The symptoms of schizophrenia are often divided into positive and negative symptoms.

“Positive” symptoms include psychosis:

• Hallucinations e.g. hearing, smelling, feeling or seeing something that isn’t there. Hearing voices is the most common problem. These can seem utterly real to the person. Although the voices can be pleasant, they are more often rude, critical, abusive or annoying.
• Delusions - believing something to be completely true even though others find your ideas strange and can't work out how you've come to believe them.
• Difficulty thinking – you find it hard to concentrate and tend to drift from one idea to another. Other people can find it hard to understand you.
• Feeling controlled – you may feel that your thoughts are vanishing, or that they are not your own, or that your body is being taken over and controlled by someone else.

“Negative” symptoms include:

• Loss of interest, energy and emotions. You may not bother to get up or go out of the house. You don't get round to routine jobs like washing, tidying, or looking after your clothes. You may feel uncomfortable with other people.
• Some people hear voices without negative symptoms. Others have delusions but few other problems. If someone has only muddled thinking and negative symptoms, the problem may not be recognised for years.

^{Updated 10.11} 

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Because everyone is unique, everyone's symptoms are different. So, it's not always clear what the right diagnosis is. Here is a list of some other possible causes for schizophrenia. This is not meant to be a textbook list, just some ideas. Some of these can be very rare indeed. Sometimes it doesn't matter anyway as the psychotic symptoms need to be treated anyway, no matter what causes them.

• Prescribed medicine-induced e.g. some anticonvulsants (at higher doses), rarely with some antidepressants, memantine, treatments for Parkinson's disease (e.g. Sinemet, Madopar), some heart drugs (e.g. beta-blockers), some malaria treatments (e.g. mefloquine), high doses of steroids
• Substance misuse e.g. cannabis, amphetamines, cocaine, methamphetamine, LSD, magic mushrooms
• Psychotic depression
• Acute GAD (or Generalised Anxiety Disorder)
• Schizoaffective disorder - both schizophrenia and bipolar mood disorder
• Delusional disorder
• Acute mania or hypomania with psychosis
• Alcoholic hallucinosis e.g. stopping alcohol (alcohol withdrawal) or long-term alcohol dependence
• A symptom of epilepsy e.g. TLE (Temporal Lobe Epilepsy)
• Acute brain injury e.g. infections, trauma/damage, stroke
• Brain lesions e.g. sarcoidosis
• Brain degeneration e.g. dementia
• Brain infections e.g. neurosyphilis
• Brain tumours
• OCD (Obsessive Compulsive Disorder)
• Social anxiety - sometimes schizophrenia can first show as social anxiety
• Metabolic problems e.g. over-active or under-active thyroid, vitamin deficiencies
• Very rare conditions e.g. Wilson's disease etc

Just to confuse matters further, sometimes people have more than one illness (sometimes called "co-morbidity"). For example, if 1 in 10 people get depressed and 1 in 10 people get anxiety, then just by chance 1 in 10 of the depressed people get anxiety as well. However, if you're depressed, you're more likely to be anxious. Co-morbidity means what else the person is more likely to have at the same time. This can make diagnosis more difficult.

• Depression - after 2 years, 1 in 30 people (30%) with schizophrenia will have depression; after 5 years, 1 in 10 (7-15%) will have depression; and after 12 years, 1 in 4 (25%) will have had depression
• OCD (Obsessive Compulsive Disorder) - 1 in 4 people (25%) with schizophrenia may have OCD symptoms, and maybe 1 in 6 (15%) will have full symptoms
• Insomnia - 44% (over 2 in 5) people with schizophrenia have insomnia (Palmese 2011), have more problems getting to sleep, and take more than twice as long (38mins vs 16mins) to get to sleep (Lusignan 2010). Insomnia can lead to night eating and insomnia.

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Basically, anyone can get schizophrenia. It seems, however, that schizophrenia is caused by a combination of genes, environment and trigger factors. Genes you inherit from your parents may give you the susceptibility, environment can make the person more vulnerable and trigger factors start it. This is not a complete list but some of the main "risk factors" that make it more likely that someone will get schizophrenia:

Genetics - if you have:

• An identical twin with schizophrenia you are 46 times more likely to get schizophrenia

• Both parents with schizophrenia you are 40 times more likely to get schizophrenia

• Non-identical twin with schizophrenia you are 14 times more likely to get schizophrenia

• One parent with schizophrenia you are 10 times more likely to get schizophrenia

• Brother or sister (non-twin) with schizophrenia you are 10 times more likely to get schizophrenia

• Child with schizophrenia you are 5 times more likely to get schizophrenia

However, you don't always need to have a relative in schizophrenia to have the genes that make schizophrenia more likely. Something called "spontaneous mutations" can occur - this is where there an error occurs when some genes are being copied, either in the egg or just after fertilisation. You can read more about this on the NHS Choices website here.

Developmental - if you have had:

• Delayed milestones (e.g. walking, talking) you are 3 times more likely to get schizophrenia

• Speech problems you are 3 times more likely to get schizophrenia

• Brain changes you are twice as likely to get schizophrenia

Childhood - if you:

• Are an immigrant or from an ethnic minority (which may add stress) you are 5 times more likely to get schizophrenia

• Used cannabis a lot before 18 you are twice as likely to get schizophrenia

• Were a solitary child you are twice as likely to get schizophrenia

Birth - if you:

• Had birth complications you are twice as likely to get schizophrenia

• Were born in winter you are one and a half times as likely to get schizophrenia

• Born in a city you are one and a half times as likely to get schizophrenia

• Had a mother who had influenza during pregnancy, you are no more likely to get schizophrenia

• Had low vitamin D at birth - this doubles chances of getting schizophrenia, so using supplements might be a good idea ^{(McGrath 2010)}

• Had a low birth weight ^{(Abel 2010)}

Most people with schizophrenia will have psychotic symptoms. This psychosis is probably mainly caused by an increase in dopamine in some parts of the brain. Dopamine is one of the brain's main chemical messengers. In one area of the brain (the mesocortical) it takes in information (e.g. what you can see, hear, smell, feel) and controls what the brain does with that information. We know that too much dopamine in that area of the brain causes the symptoms of psychosis e.g. hallucinations, delusions, paranoia. We know this because drugs which increase dopamine a lot (e.g. cannabis, amphetamines, some treatments for Parkinson's Disease) can cause psychosis. All the medicines used to treat the symptoms of schizophrenia reduce the effect of dopamine.

^{Updated 8.11}

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The list here includes most of the main options but does not say what works and doesn't. Many may be used in combination. Most herbal and alternative therapies have not really been tested in the same rigorous way that medicines have.

Our aim is to try to help people who are taking medication (or should be) get the right medicine, dose and take it regularly for as long as is right. Any medicines should usually be part of the overall treatment, although some people are quite happy just to stick with drugs or talking treatments. If your medicines are right, then everything else can fall into place. If the medicines are wrong, then they may make the symptoms worse and self-help will not be as useful.

Treatments and help should take into account the person's needs and choices.

Self-help

• Avoiding things that can make it worse e.g. smoking cannabis or taking other illicit drugs.
• Stress can make the symptoms worse
• Not drinking too much caffeine, which can make the symptoms worse and more difficult to treat
• Taking any medicines regularly and reliably
• Eating healthily (perhaps including Omega-3 fatty acids) and taking exercise ("exercise to energise") or being active. Three studies have shown that regular exercise really helps negative symptoms and physical health (although that's easier said than done), but has no effect on positive symptoms (Gorczynski 2010).
• You should have a health check every year by your GP. This is because the illness and medication can put you at a higher risk of gaining weight, diabetes, heart disease high cholesterol etc. So, make sure you have your health check every year as your GP may not always remember

Help from others

• Support from families and friends and services such as supported housing, day care and employment schemes are vitally important help a person cope with the symptoms and reduce the risk of relapse
• Befriending is also really helpful (and as effective as CBT, see below) for many people for as long as it carries on.
• Talking treatments - these can include Cognitive Behavioural Therapy (CBT, which helps people cope with the symptoms), family therapies (to help the person and familes cope better) and arts therapies (to help with negative symptoms). While CBT isn't much help when someone is acutely ill, it may help people who get a bit better with medicines, or where their insight is poor. Counselling and supportive psychotherapy (helpful with support and talking things over) can also be useful but should not usually be used (e.g. NICE and SIGN)
• Having psychosocial therapy, along with medicines, may help people with a first episode ^{(Zhao 2010)}
• Alternative therapies such as aromatherapy, hypnosis or hypnotherapy, homeopathy (treating like with like) can be used in conjunction with (but not relied on to replace) conventional treatments. The evidence for these treatments is not very good, especially in psychosis. All of these can be used in conjunction with other therapies. If they help then that is fine and we wouldn't knock them. Click here for a balanced review of complementary and alternative therapies from the Royal College of Psychiatrists (e.g. Ginkgo, Sage, vitamins, other herbals etc, and some useful links).

Medicines

• Antipsychotics are the main treatments for psychosis and the symptoms of schizophrenia. They should be used as early as possible after symptoms start, as this might prevent the symptoms and illness getting worse. Antipsychotics help the treatment of acute episodes and also to prevent relapse. In someone acutely unwell, they are often used in combination with a sedative, along with reassurance and management to help protect the person from harm.

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If you are prescribed a medicine, then there may be many reasons why that one has been chosen. These might include:

• side effects (which ones are important to you)
• local policies or agreements (such as what your GP surgery uses or agreements in your area)
• national policies (e.g. NICE, SIGN - see last question)
• familiarity (it may be better for prescribers to use medicines they are familiar with)
• relative costs for similar medicines (if two medicines are very similar, why waste money on the more expensive one?)
• personal preference (either yours or your prescriber)
• how bad your symptoms are
• any medicine you might have done well with in the past (as it's more likely to work again)

The main medicine treatment options are listed below. They are divided into "Main medicines" and "Others".

For convenience, the "Main medicines” are those medicines that are officially "approved" to treat the condition or symptoms (www.bnf.org/bnf/) and which are listed in the British National Formulary (BNF). To be listed in the BNF there needs to be good evidence that the medicine works and that the manufacturers have applied for a license (a long and costly exercise). "Others" are those medicines where there is some evidence that they help, but either not enough for a license or that no license has been applied for. These should usually only be used where other standard treatments have failed.  

In the mid-1950s, several medications appeared that could reduce the symptoms of schizophrenia. They became known as "antipsychotic" medications. These older drugs are now called "typical"or "first-generation" antipsychotics. They work by reducing the action of a particular chemical messenger in the brain called dopamine.

Since the mid-1990s, several newer antipsychotics have appeared. They work on similar chemical messengers in the brain (such as dopamine and serotonin) and are often called the newer, "atypical" or "second-generation" antipsychotics. They may be less likely to cause Parkinsonian side-effects (such as tremor, shake, muscle stiffness) and sexual side effects, although they may cause weight gain.

It has been generally considered that the newer atypical or second-generation antipsychotics (SGA) are overall a bit better than the older ones. However, two large independent studies (no drug companies involved!) published in 2005 and 2006 called CATIE and CUtLASS have shown that the antipsychotics are as effective as each other but with DIFFERENT side effects rather than some of them having LESS (or fewer) side effects. So, the choice should be based on how you do on a medicine and what side effects are important to you.

Clozapine is really the only antipsychotic that has been shown to be better than the others. However, it also has lots of side effects (and one rare but potentially nasty one that means people taking it have to have regular blood tests) so isn't used unless at least two other antipsychotics have been tried and haven't worked.

Click on the link to take you to information about antipsychotic medication.  

Sometimes the symptoms of schizophrenia can become very severe. This can result in the person becoming very distressed and/or too difficult to cope with and might need to be admitted to hospital. This might then become what is called an "acute psychiatric emergency" or crisis. The treatments for this may need to include some other medicines just to calm the person down and prevent harm to that person, or others. If this happens, follow the link to some information that might help explain what might be going on.

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Download a handy summary chart (PDF format) comparing the main medicines for schizophrenia e.g. names, how they work, doses, how long they take to work, some side effects, how long to take and how to stop.

Alternatively you can read the chart now in the window below. Use the controls at the bottom of the window to navigate through the chart and magnify the information. The 'Download', 'Print' and 'Fullscreen' links at the top of the window are particularly helpful.

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You should think carefully about taking any chemical that affects your body, including your brain. So think carefully before your next cup of tea or coffee! People are often concerned that medicines are not natural, they effect your brain, don't cure anything, have side effects and that talking therapies are better. Click here for the low-down on this (link coming soon).

This is a controversial area in psychosis and schizophrenia, but it is quite clear that antipsychotic medicines do reduce psychotic symptoms and reduces the chance of them coming back.

For an appeal for everyone to have a sense of balance about medicines and talking therapies please click here for our take on it.

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You need to refer to the answer on antipsychotic medication below

For a first episode it is not certain exactly how long to keep taking an antipsychotic but at least two years massively reduces the chances of the symptoms coming back. If someone can find an antipsychotic that doesn't give too many side effects, that is probably quite a good deal. It may also be that the antipsychotics not only prevent schizophrenia getting worse, if taken early might even stop it happening at all. The longer someone has psychotic symptoms without treatment (the "Duration of Untreated Psychosis" or DUP) the less chance there is of getting better.

If you have more than one episode, then taking antipsychotics for at least 5 years will reduce your chances of becoming ill again. The choice must be yours. If you are getting side effects, it may be possible (and a good idea) to reduce your dose a little. The dose that keeps you well may not need to be as high as the dose that got you well.

If you have stopped taking antipsychotic medication, you should be followed up for a couple of years for signs of relapse. It is quite common to become ill again three to six months after stopping an antipsychotic and it is best to deal with this early rather than let it go too far.

Information from the large, independent CATIE study (see above) suggests that if you keep switching medicines, then the response (positive effect) seems to reduce each time. This isn't saying that you shouldn't switch but that it would be a good idea to get the best out of one medicine before going to the next one e.g. altering the doses, timing, managing side effects as much as possible. The next medicine isn't likely to be perfect either.

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You need to refer to the answer on antipsychotic medication below

Before going onto another medicine, it is worth trying to get the best out of the first one. There is a risk that switching medicines too quickly means you don’t get the best out of one medicine. Then perhaps you start to search for the “magic bullet”, expecting the drugs to work quicker and having less patience. There are of course no “magic bullets”. Most symptoms have started to happen over a few weeks, months or years, not a few days, so it is perhaps unfair to expect them to go over a few days. The symptoms are more likely to go gradually over weeks or months. If side effects are the main problem with a medicine, try to cope with these by e.g. changing times, splitting the dose, manage side effects etc.

The best thing to do is set out your aims of success of any treatment in advance and be realistic. If you decide to stop, then that’s your decision, but make sure you consider the chances of becoming unwell again (and consequences of that to yourself and the people close to you).

First episode:

If someone’s symptoms have not improved after about two weeks and isn’t getting too many side effects, then usually the dose should be increased. If no better at four weeks at a good dose, then usually switching to another antipsychotic is the best plan. If the person is getting side effects they can’t cope with then it may be a good idea to switch to another antipsychotic a bit earlier.

Acute psychosis

If someone is suffering from an acute psychosis, most people will start to improve within in 3-4 weeks at the latest. Often the symptoms will reduce in a few days. If there has been no improvement over 6-8 weeks, then increasing the dose further is unlikely to help. It may take a while to find the right dose, which gives the right balance betweem effect and side effects.

Clozapine can only be used for “treatment-resistant schizophrenia” that has not got better with two other antipsychotics taken at the right dose for enough time. If no improvement occurs after 3 weeks at any dose of clozapine, it is unlikely to be any better at that dose, but some studies have shown a gradual improvement accumulating over 6 months or longer.

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There are no easy answers to this and it is a very individual choice. Generally one medicine should always be the aim but combinations (often called “polypharmacy”) sometimes help. It is rarely of any use to combine drugs with similar ways of working. Below are some of the combinations that are used with the reasons. This is not a complete list but you might want to talk to your prescriber about any combinations not on this list you may be prescribed.

Although combinations of antipsychotics have been used quite a lot, the general aim is to get the best out of one antipsychotic e.g. fiddle with the dose and timings to get the best effect with the least side effects. Sometimes adding another antipsychotic to clozapine is tried if clozapine has only been partly effective.

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If you want to read up a bit more on the best treatments, there are many guidelines that you can look at. Probably the most important of these for England and Wales are those produced by NICE (the National Institute for Health and Clinical Excellence). NICE is an independent body that is asked to produce advice about preventing and treating illnesses and promoting good health. Scotland and Northern Ireland have their own similar bodies.

Each set of NICE Guidelines is written by an independent and carefully chosen group of specialists and experts (including service users and carers). They carefully review the available evidence and base their guidelines on this.

There are two main types of NICE guidance:

• "Technology appraisal". These look at an "intervention" (i.e. a medicine, a surgical operation etc) and decide if they think the evidence is good enough to make this intervention a standard and/or if it is cost-effective compared to other treatments

• "Clinical guidelines", which look at a particular condition (e.g. hypertension, lung cancer, depression, Parkinson's disease, bipolar disorder etc) and give guidelines covering medicines, services, support etc.

The guidelines are well intentioned and give generally sound guidance (although these are sometimes controversial). They are, however, only "guidelines", so are not rigid instructions.

When NICE issues a guideline, it produces a full set, and all of these are available on the NICE website:

• Full guideline (very long and detailed, often several hundred pages, for anorak healthcare professionals only)

• Official guideline (usually 10-30 pages, the summary version for healthcare professionals)

• Quick reference guideline for healthcare professionals (usually only a couple of pages)

• User-friendly summary for service users, carers and the general public

These should then be reviewed, usually about 4-5 years or sooner if more information becomes available.

As a general rule, you should start with treatments recommended by NICE as these are the ones with most evidence that they work. However, if these do not help you, it may be useful to try other treatments.

• NICE (click here for the schizophrenia guidelines)

• Scottish Intercollegiate Guidelines Network (SIGN), where there is a guideline on Psychosocial interventions in the management of schizophrenia (2005)

• Northern Ireland

There are plenty of other guidelines and so-called "consensus statements" (where a group of experts and specialists pool their ideas, based on their own experiences as well as what the published papers say, rather than just what the published studies say). These will have been produced for healthcare professionals by such bodies as BAP (British Association for Psychopharmacology).

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The resources below provide specialist information on schizophrenia. Please note that this is not an exhaustive list. We welcome your feedback on resources that you think should be listed here.

Rethink, Head Office, 5th Floor, Royal London House, 22-25 Finsbury Square, London EC2A 1DX, 0845-456 0455 http://www.rethink.org/

MIND, 15-19, Broadway, London E15 4BQ 0208 519 2122, http://www.mind.org.uk/

SANE, 1st floor, Cityside House, 40, Adler Street, London E1 1EE  0845 767 8000  http://www.sane.org.uk/

Mental Health Ireland has a great links page on this extensive site

Your Mental Health Ireland, with a young person’s page as well

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