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We would like to acknowledge and thank the following people who made our Conference possible:

'Healthy Dundee' for their support.
Iain Swayne - Tayside Health Board for Chairing; Mary Weir - Chief Executive - National Schizophrenia Fellowship (Scotland) for providing ongoing support.
Speakers: Dr Iain Glen - Honorary Consultant Psychiatrist, Craig Dunain Hospital, Inverness; Victor Morton - Clinical Nurse Specialist in Cognative Behaviour Therapy, Ninewells Hospital, Dundee; Professor Rex Last - NSF(S) Carers Group, Tayside; Irene Sharkie - Assistant Clinical Director of Pharmacy, Tayside Primary Care NHS Trust; Dr Peter Dick, NSF (Scotland) Medical Adviser, Dundee.
Workshop facilitators for their valuable contributions:

Catherine Marriott - Stress Management Consultant, Dundee; CRISP Team, Community Rehabilitation Integration Support Project, Rosie Summerton - Arts Advocacy, Dundee Rep; Marjorie Sprunt - Hearing Voices Network, Fife; Barbara James - Multi-Cultural Health Worker, Tayside Primary Care NHS Trust.

Dale and Fiona at NSF(S) National Office for their valuable advice and practical help. Staff at the Dundee College Kingsway Campus for their organising and catering.

A final thank you to all those who came along and supported the Conference, and made a big contribution to the day.

Cathy Hamilton
Carers Support Officer (Tayside)

New Directions in the Treatment of Schizophrenia is an initiative by Tayside Carers Support Project - National Schizophrenia Fellowship (Scotland)

We hope to provide carers with information and education, which will allow them to develop an even deeper understanding of mental health issues, and maximise their coping skills.

Most carers are faced on a daily basis with behaviour which is challenging, confusing, frightening and difficult. Their lives are incredibly stressful, not only because of the difficulties of caring for someone with a severe and enduring mental illness, but also because of the stigma and fear that mental illness, especially schizophrenia produces.

It is therefore not surprising that carers become socially isolated and often end up seeking help for themselves for anxiety disorders and depression. The Conference also aims to be a vehicle for carers to meet each other, offer each other mutual support, learn new coping strategies, and how to cope with the demands and stresses that are placed upon them, thereby reducing the risk of mental health problems for themselves.

There may also be an opportunity to take this even further, by developing the Carers Support Group. It is hoped that the Conference through the speakers and workshops will achieve all these things.

The different, and new directions that are presented, will give plenty of food for thought. As far as the workshops are concerned, it seemed a good idea that since this Conference was for carers, we would look at ways in which carers can be offered a chance to find out about a variety of projects. These included the Stress Management Service, Arts Advocacy, Hearing Voices, and an understanding of what difficulties the Ethnic Community have to face.

The workshops would also give carers/professionals the opportunity to meet each other, exchange ideas, voice opinions, and allow professionals the opportunity to take on board, what the carers are saying.

Dr Iain Glen

The burden of schizophrenia, affecting as it does one per cent of the world population, is a heavy one for sufferers, their families and society. Support costs in the UK are estimated at �1.5 billion per annum. This is more than the costs for heart attacks or strokes, because sufferers from schizophrenia often need lifelong care.

Yet there are still no objective tests for its diagnosis or for monitoring Community Care. This makes early diagnosis difficult and relapse prevention and subsequent hospital re-admission (the costliest part of care) haphazard at best. Why should this be?

New tranquilliser treatments came in the 1950s and the basic underlying clinical concepts of how tranquillisers work on the important dopamine system are unchanged today. New treatments with fewer side effects have been developed but their efficacy (with the exception of Clozapine which has major potential toxicity) is not significantly greater than the older conventional neuroleptic drugs.

What is more, these approaches have not led to usable point of care objective diagnostic tests. Today the diagnosis of schizophrenia is still made using symptom classification criteria which are poorly reproducible and depend on subjective assessment.

Professor R E Kendall in a plenary welcome lecture to the Glasgow CINP Congress in Glasgow in 1998, attended by 3,000 psychiatrists, emphasised this lack of progress and dissatisfaction with current models. New concepts are needed.

One such concept is that phospholipids make up the bulk of neuronal membranes and that abnormalities in these phospholipids influence the haphazard at best.

Why should this be?

New tranquilliser treatments came in the 1950s and the basic underlying clinical concepts of how tranquillisers work on the important chemical transmitters which are embedded in them. This concept in recent years has led to a new understanding of psychiatric illness, and new methods of diagnosis and treatment.

Much of the work is still in progress. A number of us have reviewed progress in a new book - Phospholipid Spectrum Disorder in Psychiatry (Peet, Glen and Horrobin, 1999, Marius Press).

What are the new concepts? Basically they concern an additional understanding of how tranquillisers work. It was believed for many years that there was a primary 'up-

regulation' of the dopamine system, i.e. that dopamine was overactive because of a primary abnormality in the dopamine system itself.

Current opinion is that there is no primary abnormality in the dopamine system. New evidence suggests that the dopamine system is overactive because of abnormalities in the cell signalling system that regulates dopamine. These cell-signalling regulators are derived from specialised fats in the cell membrane, particularly the fatty acid called arachidonic acid (AA).

Although these cell signalling systems are highly active in the nervous system, many are also present in all other cells, for example in the immune system, which is accessible in the skin. This is the basis of the skin test we have developed as an aid to the diagnosis of schizophrenia. Here niacin is applied to the skin as patches of graded concentration.

Normally this produces skin flushing through the stimulation of production of prostaglandin D2 in some skin cells. In most sufferers from schizophrenia (around 80 per cent), because of a defect in the arachidonic acid supply to the prostaglandin D2 pathway, the skin flushes poorly or not at all

The fatty acids in membranes are highly unsaturated, unstable and readily peroxidised. Special antioxidant systems have evolved in mammals to allow the co-existence of these fatty acids and oxygen. For reasons which are not entirely clear but which may be associated with excess activity of cytosolic phospholipase A2 (cPL A2), an important regulator of arachidonic acid, there is an increased release of AA from membranes in schizophrenia, and increased peroxidation.

While this has until now been measured by blood tests, new techniques now enable us to measure these increased peroxidatin products in breath. Therefore, in the skin test and the breath test potentially we have two new non-invasive tests for schizophrenia. We can also measure the amount of cPLA2 in blood, giving us a third new potential test for schizophrenia.

Finally and perhaps most importantly, these new concepts involving phospholipids have provided the possibility for treatment by fatty acids to regulate the dopamine. Exciting new results are coming in from double-blind trials of a fatty acid, eicosapentaenoic acid (EPA), in schizophrenia. The trials show significant further improvement in patients already stabilised at optimal levels of neuroleptics.

Victor Morton

The Past
People, in the past, who were diagnosed as suffering from schizophrenia, were seen as having a disease, they were viewed as being ill. Medication and hospitalisation were seen as the only treatments available. In general, schizophrenia sufferers were the poor cousins of psychological approaches.

  1. Normal reactions to stress were seen as being part of a syndrome.
  2. Psychological treatments have existed for over 30 years, but were not well accepted
  3. Psychological approaches were not commonly adapted for people with schizophrenia
  4. A small amount of research in the area of psychological treatments for schizophrenia (mostly hospital based)
Some clinicians were reluctant to see treatments as suitable.

The Present
The aim of Cognitive Behaviour Therapy is to normalise the individual's experiences, and improve on current coping in conjunction with medication. Cognitive Behaviour Therapy treatments are more developed as a result of clinical trials, suggesting some benefits of treatments, in conjunction with medication. Treatments are agreed on in a collaborative way, with the patient taking an active role. The main focus of therapy is :

  1. Relapse management
  2. Working with families
  3. Working with voices
  4. Anxiety management.

The Future
What we need in the future is:

  1. Implementation of the S.I.G.N. guidelines for psychosocial interventions - for every family
  2. Individual psychotherapy for sufferers - offering sufferers an individual formulation
  3. Movement of finances tied up on hospital care
  4. (Smith 95) states that �325 million is spent on schizophrenia, the majority on hospital care
  5. More specialised training for healthcare workers - a specialised Cognitive Behaviour Therapy course.

Professor Rex Last

Today, I want to talk to you about children. No, I'm not going off the subject of the conference as I hope you'll see in a moment. What I am going to do is to approach it from an entirely different direction. I am deeply concerned about new directions in the care of the mentally ill, but I believe that it is not just the latest chemical bullet or the newest brand of cognitive therapy which can and should make the difference, valuable though they are. Other factors are just as significant in my view - if not more so. Where was I? Yes, the children.

There was a programme on Channel 4 a few days ago entitled: Do children need parents? It was an absorbing, challenging exploration of the unorthodox view that the peer group (i.e. other children) had a far greater impact on upbringing, character development and so forth than the parents.

The scientific establishment hated it. Why? First, because it was unorthodox, it didn't build on existing research in the painstaking, brick by brick conventions of academic investigation. And worst of all, the woman putting forward this view - although very well versed in the subject - didn't have a conventional scientific background. She hadn't climbed up the slippery pole via PhDs, refereed research papers and the rest. So the whole thing was condemned out of hand.

What's that got to do with New Directions in the Treatment of Schizophrenia? A whole lot, in my view. The medical establishment has to do two things which can transform the care and treatment of the mentally ill:

they must dare to think differently and

they must accept that they aren't the only experts on the block. And then perhaps some real advances will take place in the care and treatment of users.

I firmly believe that the way people are treated is as important, if not more important, than what they are treated with. For example, a user emerging from a florid episode is allowed to leave hospital, is found a flat, given daytime activities, and has his or her DLA (Disabled Living Allowance) and other benefits evaluated.

Fine, but in the current system 9 times out of 10 this means that the user gets interviewed at least four times by four different people and asked the same daft questions like what is your name, how old are you and who is your GP.

No one seems to have cottoned on to the fact that every one of those interventions will cause serious stress and upset to the user and he or she may end up feeling a whole lot worse because of them, although they were designed to achieve the exact opposite. Ask the questions just once and get the professionals to coordinate their work, and the stress goes away. Simple? in an ideal world, perhaps.

The establishment has to dare to think differently, to undergo real cultural changes, not just to nod politically correctly in the direction of joint working with housing, GPs, social work and the voluntary sector, but to do something about it in real terms on the ground.

The patient isn't divided up into separate needs, he or she is one whole person, so why carve up the delivery of those needs? So the seamless delivery of care based on sensitive needs assessment will in itself transform the treatment of the user of mental health services.

And what about my second point, about who the real experts are? I know from personal experience and from the experience of other carers that we may not be the top experts on pharmacology, psychiatry, cognitive therapy and the whole alphabet soup of specialisms surrounding the care of the mentally ill, but we are experts in one subject - the user who is in our care.

The experts ignore that invaluable resource at their peril - and believe me, they have, time after time. I have lost count of the number of occasions when I have heard of a carer stating unequivocally that their son, daughter, wife or husband is, quotes an accident waiting to happen.

They can see all the signs of deterioration because of the fact that they've lived with that person over years, decades maybe, and know them inside out. They can see the signs. But because they haven't got the medical degree, and qualifications, they are ignored. And more often than not, the accident happens, sometimes with fatal results.

Including the carer or carers as part of the loop, as a full member of the professional team delivering care for the user, would again transform mental health care. Just as would the cultural change in health, social work, housing and the other providers. The voluntary organisations in Scotland are getting very good at joint working and joint commissioning. Now it is the turn of the statutory sector.

Let me now turn to other ideas in which new directions in the treatment of mental illness are crying out to be implemented. The first is yet another area in which new directions in the treatment of schizophrenia can be created. It's one I hinted at a moment or two ago when I spoke about treating the whole patient holistically. This one will require government action, though.

I believe that the logical conclusion of the shift towards the joint delivery of care is that the damaging and entirely false divisions in mental illness between medical and social need should be abolished.

They are all part of a seamless spectrum of need. A decent flat, money for a reasonable lifestyle, a volunteer befriender, a daytime drop in - these are just as much part and parcel of the treatment and rehabilitation of the user as the depot or the handfuls of pills they have to swallow.

The next area concerns the daft but still persistent notion that becoming mentally ill means you are brain dead, that your intellectual facilities have atrophied. Remember the programme about the physically handicapped: Does he take sugar? I'd like to call this similar attitude to mental illness: Does he take procyclidine?

All too often the assumption is that the user can cope only with mindless tasks like basket weaving and art therapy - valuable though they may be in their place - without recognising that, apart from anything else, this is a generation brought up with computers and modern technology who would benefit enormously from what IT can offer. Interaction with a computer which doesn't have a threatening human personality is one excellent way of bringing many users back to something approaching normality in their daily lives.

The mentally ill are not subhuman, they are ordinary folk like you and me, and let's face it, one in four of us who go to the doctor are presenting with some form of mental unwellness, to put it at its mildest, so mental illness impacts on all our lives.

I've not quite done yet. The next area for new directions in treatment is in the simple word information. Carers and users must be given the fullest possible information. Not just factual information, either. Information about what it feels like to be or care for the mentally ill, how to cope, how to react, and how others have faced the same challenges.

Once again, though, that requires a cultural change on the part of the establishment. Knowledge is power, and if it gets into the wrong hands, people may actually start to challenge the consultant and ask about different forms of treatment. And that kind of thing would never do.

Dare I say that in my view, information - or rather proper access to information - has in itself a hugely important therapeutic value, especially for the carer trying to come to terms with and cope with a loved one who is in the early stages of mental illness. The knowledge that they are not alone, that information is out there which can be tapped and drawn upon is of the greatest significance.

There's one new direction that concerns me a great deal. It comes from New Labour, from the government's apparent obsession with the notion that people who are not in work are workshy, and that the mentally ill, particularly the recovering mentally ill, are going to be caught in the trap of looking well, acting well and being persuaded that they really ought to be back in the workplace, often with devastating results when they discover too late that they can't cope.

Another area for a new direction is stigma. Briefly - and this is a large and very important topic which deserves, and has received, whole conferences to itself: Has it ever occurred to you just how good society has become at trying to legislate bad behaviour out of existence? It wasn't until seat belts became compulsory that people reluctantly started to clunk click on nearly every trip. And then there came the laws against discrimination: on grounds of sex, race, gender - even age is being touted as the next on the list of politically incorrect things not to discriminate against.

What about mental illness? It's way past time that this stigma was confronted by society in the same way as other kinds of discrimination. It will take a while, and maybe not until there are real breakthroughs in treatment, as happened with the big C of cancer which isn't such an ogre now as it used to be. But beat stigma - or at least considerably reduce it - and you bring about a vastly significant new direction in the treatment of mental illness.

Finally (one of the most keenly anticipated words in any speech). Finally - prevention. The worst aspect of the medical model of human beings has been the emphasis on treating established illness, fire fighting as it's known in many professions. Waiting until something goes wrong and then patching and mending to make it better. And let's face it, there's far more glamour and much more funding attached to heart/lung bypass operations than to cervical smears or screening for breast cancer.

It was only when consultant posts were created in the Cinderella service of Accident and Emergency that this aspect of medical care gained the prominence and high profile that it deserved. How's about a consultancy or two in preventative psychiatry?

Take the bottom line of what it costs to care for the long term mentally ill, and I don't just mean pounds and pence, I mean cost in trauma to the patient and his or her family, cost to the community at large, and the waste of human life and the denial of happiness and a fulfilling existence. If just a proportion of the one in a hundred could be detected and spared that first florid episode, that truly would be a great advance, a key new direction in the treatment of mental illness.

So that's it. I believe firmly that, to coin a phrase, there is more than one way to skin a cat, and new directions in the treatment of schizophrenia doesn't just lie in the hands of those researching new medical interventions. In a real sense, it's up to all of us in one way or another. We'll never entirely rid our society of the scourge of mental illness, but there's a vast amount more we could and should be doing which will mitigate its impact. We can:

Am I hopeful that some of these things will happen? Not excessively so, as the NHS for one is a huge ship that takes an age to stop and turn in a different direction, but the signs are positive. That programme on Channel 4 I referred to at the beginning of this talk, whatever the merits of the case, offered a breath of fresh air from someone prepared to think in an unorthodox and challenging way.

It needs us as carers and all those involved one way or another in mental health issues to be equally prepared to think anew, to keep pressing for change, for - in every sense of the term, new directions in the treatment of schizophrenia.

Dr Peter Dick

Prior to the development of Community Mental Health Teams, there was a clear split in service organisation with secondary care predominantly providing services to people with severe mental illness (which is relatively uncommon) often in an institutional or day treatment setting and primary care providing services for people with mild to moderate illness (which is very common).

Improved access to Mental Health Services through Community Mental Health Teams has had many beneficial effects. A downside however from the perspective of people suffering from severe mental illness and their carers is that resources available to them may be reduced (through competition from other demands).

This happens because people with schizophrenia and their carers contrary to the popular view generally suffer in silence through long experience of having to cope largely on their own. People with mild to moderate illness in contrast, who are used to feeling well, expect help when they hit a bad patch and are more likely to get it.

The best way round this is to ensure that the government meets its stated intention of prioritising services for people with severe mental illness. They suggest that we should do this through identifying those who are suffering, systematically assess their needs, and ensure that services are developed to meet these needs.

Evidence from international studies suggests that for people with chronic severe mental illness, this can best be done through an approach called Assertive Community Treatment.

Key characteristics of this approach include intensive input with staff having low case loads and working extended hours, co-working whereby the sufferer and family can have access to different team members all of whom are familiar with their circumstances, integration of the different aspects of care and input without a defined time limit.

This approach is expensive in terms of existing community treatments but cheap in terms of hospital treatment. If it is used appropriately therefore, it can result in an improved service without additional costs and help people to be treated in the community.

The problem is that reorganising services is a major task and without consistent input from organisations such as National Schizophrenia Fellowship (Scotland) and carers locally there is a risk that hospital provision will be reduced, but the community services that we know will work for people who have previously been hospitalised, will not be developed to the extent that is required.

Irene Sharkie

Why are antipsychotics prescribed?

How do they work?

Development of antipsychotics

  • Mid 1930s Promethazine
  • 1950s Chlorpromazine (Largactil)
  • 1958 Haloperidol
  • 1960s Mode of action of haloperidol was described (Dopamine Theory)

Clozapine - History of its use:

  • Introduced early 1960s
  • Withdrawn 1975 due to side-effects on the blood
  • Effective against 'positive' and negative symptoms
  • Relaunched 1990

Effects of Clozapine:

  • It affects quite a number of chemicals in the brain - not just dopamine
  • Less likely to cause movement disorders - 'atypical'
  • Blood monitoring is required.

Further developments

  • From 1990 onwards there was a search for new compounds
  • Advantage of Clozapine with respect to efficacy and less likelihood to
  • cause movement disorders
  • No blood monitoring requirements

Development of atypical drugs

  • 1993 Risperidone
  • July 1996 Serindole (Now withdrawn)
  • September 1996 Olanzapine
  • September 1997 Quetiapine
  • 1998 Amisulpiride
  • 1999 Zotepine
  • 2000+ ?

Newer atypicals vs typicals

  • Equally effective against positive symptoms (except Clozapine)
  • Tend to be more effective against negative symptoms
  • Less likely to cause stiffness, facial movements, tremor, restlessness and tardive dyskinesia

Atypicals vs typicals

  • Both can cause drowsiness, weight gain, sexual problems, changes in blood pressure, dry mouth, constipation, sensitivity to sunlight - products differ
  • Atypicals only available by mouth
  • Tend to be less frequent dosing

Main problems with antipsychotics

  • Side effects/acceptability
  • Compliance
  • Interactions with other medicines (including alcohol and medicines bought over the counter)

In summary

  • The ideal agent is yet to be found
  • Tremendous progress has been made in the last 10 years
  • The future is very optimistic
  • Increased choice helps to maximise benefit and minimise side-effects
  • Compliance remains a major issue and depot atypicals are not yet available

Points to remember

  • Don't be afraid to ask for more information about medicines - there are many leaflets available
  • Discuss any problems with medicines - there may be a simple solution.

There were eight workshops all together, four in the morning, and four in the afternoon.

The morning workshops:

The afternoon workshops:

The evaluation of the workshops was very positive. Terms like informative, openness, stimulating, good attitudes and alliances, were all used to describe how both carers and professionals felt.

T he workshop was divided into two parts: a brief overview of our project including a brief presentation by Pat (Dundee Hearing Voices) and then two workshop groups.

The aim of the groups was to examine how theoretical perspectives impact upon service users, carers/significant others, and professionals - from two definitions - auditory hallucinations being 'auditory perceptions with no external stimulus' and hearing voices being 'auditory perceptions understood within the context of an individuals life experiences'.

The overall aim (if we had one!) was to use the time as a springboard to allow participants to consider voices as an experience which can be approached from a behavioural perspective - as a complementary approach to more traditional models of care.

Service users:
Auditory hallucinations - demeaning, confusing, frightening life experiences not respected, feel you are going mad, angry - not believed, your experiences not seen as reality. It was agreed that these experiences could lead to low self esteem, learned helplessness, negative coping strategies eg. Self harm alcohol/drug misuse, social isolation for fear of stigma.

Hearing Voices perspective:
Acceptance of the reality of voices, voices and their nature can be understood thus leading to removal of stigma and promoting control, more open communication, self determination through development of positive behavioural coping strategies (combined if necessary with appropriate medication).

Carers/Professionals:
Auditory hallucinations - Power remains with these groups Carer/professional knows best - well intentioned often trying to protect their relative/client, carers express that the sense of responsibility for relative's wellbeing is often overwhelming, labelling, that is, diagnosis is necessary to obtain services thus reinforcing the disempowerment cycle. Often carers are afraid to talk about voices - maybe more training is required to remove fear of relapse.

Hearing Voices Perspective:
Service user led, open communication, experiences respected and shared, clear boundaries have to be developed as a result and the need for specialist counselling services acknowledged, the nature of voices is of prime importance and their effect upon service user thus carers/professionals are better equipped to understand behavioural strategies developed by voice hearing person, coping strategies can be explored and developed empowering service user to take more control of their mental health.

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