Living With Schizophrenia

Today, 10 October, is World Mental Health Day. This is a day set aside by the WHO for people all over the world to focus on the importance of Mental Health to human society, and to pay especial attention to the scourge represented by mental illness in all its varieties. Dr Femi Olugbile examines Schizophrenia

It is a truism to repeat the slogan ‘There is no Health without Mental Health’. There are a lot of important issues associated with Mental Health and Illness that justify a constant effort to keep the subjects in the public eye. Some of the facts are as follows:

•Up to one in every ten human beings should expect at some time in their lives to suffer from a significant mental health issue.

•Mental illness of different types, most frequently Depression, are among the highest causes of Disability Adjusted Life Years (DALYs) – which is a major measure of the loss of productive life suffered as a result of different types of illness all over the world.

•In Nigeria, more than ninety per cent of people with a diagnosable mental illness never get to see a doctor or receive treatment of any sort.

•The cost of untreated mental illness to society in terms of lost productivity every year is humongous – estimated in the hundreds of billions of naira.

This year the theme of the World Mental Health Day is Living With Schizophrenia.

What is Schizophrenia?

It is an illness, or a group of illnesses, in which the individual loses touch with reality, and may experience a variety of strange feelings, such a conviction that he is being controlled by others, or his thoughts are being ‘broadcast’ and made available to other people, or that thoughts are being put in his mind or taken away from him. He may hear voices of people running commentaries on his actions.

There are a whole range of other symptoms that a person suffering from this curious but common illness may experience, including some types which manifest with so-called ‘Negative Symptoms’ (flat facial expression, lack of motivation etc). There are a number of different sub-types of the illness, with slightly different pictures and outcomes.

Schizophrenia is an illness that probably has been with man from the beginning of time. It is slightly more common in men than women. It may affect any age group, from childhood to late old age, although it most commonly begins in people in their twenties and thirties.

How common is Schizophrenia?

It is a relatively common illness – about one out of every hundred human beings may expect to suffer the illness at some time in their lives.

Although there are cultural differences in the content of the experience, Schizophrenia is known to occur with roughly the same likelihood in all races and cultures.

Many of the obviously mentally ill destitutes who wander about on the streets of Nigerian towns are suffering from long-standing Schizophrenia. In a similar way, many of the clients who are admitted to long-stay mental health facilities are suffering from Schizophrenia.

What causes Schizophrenia?

Genetics: A person with one parent who suffers from Schizophrenia has a higher risk of developing the illness than another person who has no such history. The risk is significantly increased if both parents suffer from the condition.

Family and Social Environment:  Some early theories suggested that certain patterns of family interaction could predispose some people to developing Schizophrenia in later years. Mothers especially were made to feel guilty if their children went on to develop the illness. There is no conclusive evidence on the matter. On the other hand, certain events such as Emigration, and belonging to an alienated minority are associated with a relatively higher incidence of Schizophrenia.

Drugs: Some drugs of abuse such as cannabis (Indian hemp) may cause symptoms similar to Schizophrenia as an acute illness, while long term use may lead to symptoms indistinguishable from Chronic Schizophrenia.

Factors such as Stress may precipitate the onset of Schizophrenia in a person who is vulnerable to the condition.

Abnormalities in Brain Substance: Certain physical changes in the brain are found on MRI and CT scan in many people who have had the condition for a long time. Whether this is ‘cause’ or ‘consequence’ of the illness has not been fully established.

Abnormalities in Brain Chemistry: The effective activity of the first generation of drugs discovered for treating the condition was found to be due to reduction of activity at dopamine receptor sites in a part of the brain known as the ‘meso-limbic’ system. This suggested that excessive neurochemical activity at these sites might be responsible for the symptoms of Schizophrenia. Again whether this is ‘cause’, ‘consequence’ or ‘incidental’ is not fully established, though the fact that the medicines that target those sites have the effect of improving the symptoms suggest a strong relationship.

How can I recognize a relative who has Schizophrenia?

A person with Schizophrenia may be observed talking aloud as he responds to voices he is hearing. The speech may be incoherent. There may be a variety of false beliefs (for example that his life is in danger) and unusual experiences as earlier described. Because the individual is out of touch with reality, he may not be aware that he is ill and in need of treatment and so may resist any effort to help him.

How can I help a relative or colleague who has Schizophrenia?

The first important requirement is that a person who is showing obvious disturbance in behavior or thinking should be assisted to get access to expert assessment and treatment as soon as possible. The fact that the sufferer may be out of touch with reality and lacking insight into his condition implies that he may not willingly submit to examination. This is why there is provision in the nation’s laws for a person who is suspected to be suffering from a mental illness (and who may as such be a danger to himself or others) to be compulsorily taken to a place of safety (a psychiatric hospital) for observation and treatment. This may be done by relatives or the police or a medical practitioner. It may also be done on the order of a magistrate.

Can Schizophrenia be treated?

The answer is yes. Effective treatments for the condition have been available since the mid-nineteen fifties. The first major drug was Chlorpramazine  (trade name Largactil). More recently a large number of newer, smarter (and more expensive!) drugs have become the mainstay of treatment.

There are also non-drug treatments that are employed in a variable combination. These include Psychotherapy of various sorts, Cognitive Behaviour Therapy (CBT), and various Psycho-Social interventions.

Most persons who develop Schizophrenia and receive effective treatment respond positively and are able to return to some form of normal functioning within society. The long-term outcome usually depends on the client’s compliance and the amount of family and social support he is able to get.

What does living with Schizophrenia entail?

There are three important perspectives to this.

•The Client: It is a tough life, even in the most enlightened societies. There are a variety of problems, starting with the illness itself. It is an unpleasant illness to have. It is difficult for other people to imagine how scary it must be for someone to feel that he is being controlled by outside forces, or to hear voices talking about his most intimate actions when he cannot see anybody. When he gets into treatment, the Drugs have some side effects (such as a frequent tendency to put on weight) which may be a nuisance. Some may cause drowsiness or sluggishness. After treatment and discharge there is the prospect of taking medication for several years, which is hard to accept. There is, of course, the cost of the hospital and the drugs over all those years. Then there is the Stigma. All over the world, people with mental illness, even those who have had treatment and made a good recovery, are discriminated against. There are many local ‘proverbs’ which are very prejudicial against the mentally ill and their prospects in Nigeria. Marriages break up, jobs are lost as a consequence of stigma. There is an ongoing battle here, as in the rest of the world, to enlighten the public on the matter and help to minimize this scourge, but the battle is nowhere near being won yet.

•The Family: It is tough having a son, daughter, wife, or husband who has Schizophrenia. It places a significant burden on family relationships. And yet it is a proven fact that persons who are in close, caring family relationships have a far better outcome in the long term if they have Schizophrenia than people who are solitary, such as single or divorced individuals.

Professor Adeoye Lambo, the father of Nigerian Psychiatry, recognized the importance of the family in the care of the person with Schizophrenia. This was the logic behind his innovation of the Aro Village scheme, whereby persons who were admitted for treatment were allowed to stay with members of their families in circumstances similar to their natural environment. It is true for all that the symptoms of the ill individual may be difficult for his family to cope with, especially before treatment. Although the risk of violence is much exaggerated, there is occasional display of it if the situation is not properly handled, or if the ill member is made to feel endangered. The reluctance of the individual to accept help may mean the family have to take him into care against his physical resistance. Some of the behavior may be socially embarrassing. The cost of treatment may have to be borne by the family. If the individual loses his job due to stigma or prolonged hospitalization, the family may have to take up the financial burden of his sustenance. The stigma targeted at the individual may be extended to other members of the family, such as the siblings.

•The Society: A lot of misinformation and frank nonsense about the origin and nature of mental illness, especially Schizophrenia, is daily directed at the willing public in Nigeria from Nollywood. A research effort carried out some time ago at LASUTH surveyed about two hundred Nollywood movies of the Yoruba language genre. It found that at least half of them included one or more scenes of mental illness very similar to Schizophrenia. Invariably the cause was of metaphysical origin, the treatment was ‘metaphysical’ too, and the outcome was dubious at best. This reflects the popular cultural view on mental illness, but also has the effect of making the public unsympathetic to the mentally ill, even when they have had treatment and lost all their symptoms. Employers, and even landlords often find an excuse to eject a person who is known to have had a breakdown. This widely prevalent belief-system makes people try to ‘hide’ illness and drives the whole subject underground, to the detriment of society at large. It is also true that Society, as represented by government, has not put on ground enough facilities and personnel, spread all across the country, for the recognition and medical treatment of the condition.

What are we to do?

It is necessary to accept that this is a problem for all of us, and it will not go away. One in every hundred human beings will continue to have Schizophrenia at some time in their lives, whether we like it or not. We are better at treating it and minimizing its consequences now than at any other time in previous human history. However the man-made consequences, the collateral damage caused by widespread stigma, ignorance and general negative attitude and lack of understanding on the part of the public need to be vigorously tackled and overcome. That is the purpose of making ‘Living With Schizophrenia’ the topic of celebration for this year’s World Mental Health Day. There is need for more mental health workers to be employed and deployed at the grassroots for the care of the populace. The best place for a person with any mental illness to live ultimately is the community and not the hospital, so even if a person with Schizophrenia is admitted for treatment in a specialist facility, it is necessary that a system of Community Care be developed to help him ultimately fit back seamlessly into the community. (Lagos State is developing such a system and has committed itself to a Mental Health Policy that emphasizes the need), Mental wellness and the anti-stigma message must be propagated everywhere, including the schools. All the media, including Nollywood, must be recruited to drive home the message. Mental Health workers and all caregivers must approach their work with compassion and a positive spirit.

All of these measures will ultimately help our society to help all the people who in some way or other are ‘living with Schizophrenia’ – since in effect all of us are living with the problem in some way or other anyway. It will be a better day when we all begin to see the problem and its solutions in this light.