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Expert Q&A

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How canI help my schizophrenic sonwhen he stops taking his meds?

Asked By Maria, PHILADELPHIA, Pennsylvania

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Please help. My son has been diagnosed with schizophrenia. However, when he starts feeling better he won't take his medicine, which is risperidone, and it is very difficult for us to get him to take it when he is not feeling well. He is a bright young man who has lost his job many times because of this illness. Are there any new findings for this illness? Can you explain what part of the brain is affected?

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Mental Health Expert Dr. Charles Raison Psychiatrist,
Emory University Medical School

Expert answer

Dear Maria,

I am sorry to hear about your son. For many years I ran an inpatient team in a big psychiatric hospital, and the story you tell was the bane of my existence. A young person like your son would come in to the emergency room wildly psychotic. We would hospitalize him, give him a medicine like risperidone -- often against his will in the beginning -- and he would do remarkably better. Home he'd go, with all our follow-up plans in place, only to return a month or so later wildly psychotic all over again because he'd stopped taking his medicine.

When we think about schizophrenia, we tend to envision the flashier symptoms and behaviors such as hearing voices, shouting at the empty sky while pushing an overflowing shopping cart or believing that one is God or the devil. I had a patient once who believed she was the Virgin Mary and Eva Braun, Hitler's lover. I had another patient who was convinced he had died years before and someone had stolen his body. Why? Because he saw his body lying in a coffin in a church once.

In fact, while colorful, these types of symptoms are not the worst part of schizophrenia. Much worse is the fact that many people with the illness lose all insight into their situation. They believe their delusions so thoroughly, or are so thoroughly confused in general, that they can't see that something is wrong. And even when they recover, they often do not gain insight into what happened.

This lack of insight is itself a symptom of schizophrenia, and it is one of the worst. Many studies show that, other things being equal, a patient who recognizes that he is ill and complies with treatment will do much better over the years than someone without insight, who thinks he is normal and doesn't need treatment.

There are probably two reasons why having enough insight to comply with treatment improves outcomes. First, anti-psychotics suppress behaviors and delusional beliefs that make it impossible for a person to function in society. More importantly, over the last several years studies have shown that taking anti-psychotic medications early in the course of schizophrenia (i.e. as soon after it starts as possible) probably protects the brain from damage, with the result that treatment actually can slow the worsening of the disease.

It is now quite clear that each bout of psychosis damages the brain and leaves a person in worse shape than before. Think of psychotic episodes like little strokes. We all know how repeated little strokes in older people eventually destroy the brain and lead to dementia. In patients with schizophrenia, repeated bouts of psychosis (usually caused by stopping medication) also damage the brain. Remember the first modern term for schizophrenia was "dementia praecox" (early dementia).

This last point is so important that I feel the treatment of schizophrenia is one of the few places in medicine in which it can be justified to treat people against their will. Because of this belief, I always tell families that the single most important thing they can do for their sick child is to get him to take the medication on a regular basis, whatever it takes. Parents are often afraid that if they use all the leverage at their disposal to enforce medication compliance their child will come to hate them, and sadly, in my experience, this does occasionally happen. More often, though, the anger fades when the patient does better and stays as well as patients with schizophrenia can be, given our current treatment limitations.

So specifically in your case, I would recommend you do an inventory of all the points of leverage you have over your son (house, car, food, emotional support) and make these contingent on him taking his medications. It's harsh and sometimes the patient will walk, but quite often patients will take medicine just to hold onto things they need or to get things they want. In my experience it doesn't matter how the medicine gets down the gullet -- it's just got to get there for a patient to escape the pattern of improvement and relapse that you describe and that is so destructive to a patient's brain over time.

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