Schizophrenic Care: From Coping to Thriving
Updated: 1 hour ago
The goal for schizophrenia care has shifted, from symptom management to regaining functionality.
Understanding schizophrenia
In Singapore, it is regarded as the most commonly diagnosed psychotic disorder within Singapore’s healthcare system, with 2.3% of adults having experienced schizophrenia or another psychotic disorder during their lifetime according to Singapore’s 2016 Mental Health Study.
Malaysia reported an annual incidence of just five cases per 100,000 population, compared with an expected rate of 100 cases per 100,000. This discrepancy, attributed partly to delayed reporting and underreporting, suggests that the true burden of schizophrenia may be substantially underestimated, with potentially thousands of individuals remaining undiagnosed or facing delays in accessing psychiatric care.
“At its core, schizophrenia disrupts a person’s ability to distinguish what is real from what is not, a profoundly disorienting experience which can affect how they think, feel, perceive and interact with the world,” says Dr Poon Ngar Yee, Senior Consultant Psychiatrist and Co-founder of Serenity Clinic, Singapore.
Symptoms can be categorised into positive symptoms, such as hallucinations, delusions, suspiciousness and disorganised thinking, and negative symptoms, such as reduced emotional expression, diminished emotional engagement and reduced interest in social interaction.
The causes of schizophrenia are complex and multifactorial, due to the cumulative interaction between genetic predisposition and environmental risk factors. Dr Poon elaborates, “Having a family history of schizophrenia does raise the odds of developing the condition, but it does not seal the outcome. Environmental factors such as obstetric complications, maternal nutritional deprivation, childhood adversity and trauma, as well as heavy cannabis use also play a meaningful role in the risk of developing schizophrenia.”
Evolution of treatment
Discovered in 1950, chlorpromazine was the first medication that could meaningfully reduce psychotic symptoms by blocking dopamine receptors in the brain, thus reducing hallucinations and delusions.
However, chlorpromazine and other first-generation antipsychotics came with significant side effects such as movement disorders, muscle stiffness, and the risk of tardive dyskinesia, a neurological disorder characterised by repetitive, uncontrollable movements.
Dr Poon adds, “The next major shift came with second-generation (atypical) antipsychotics in the 1990s, such as olanzapine. Although they reduced movement-related side effects, large-scale trials found they were not consistently more effective than earlier drugs and carried greater metabolic risks, including weight gain, dyslipidemia and elevated blood sugar.”
Clozapine remains the gold standard for treatment-resistant schizophernia, or schizophrenia that has not responded to at least two other antipsychotic medications, although it requires regular blood monitoring due to a rare but serious risk of lowering white blood cell count.
The introduction of second-generation long-acting injectable antipsychotics (LAIs) helped address one of the biggest challenges in schizophrenia treatment: medication non-adherence. Studies show that up to 50% of patients do not take their oral antipsychotics as prescribed, while up to 80% discontinue treatment within a year.
“LAIs were able to eliminate the daily pill burden, and generally maintain more stable drug concentrations in the bloodstream compared with oral equivalents. In real-world populations, they are associated with lower relapse and hospitalisation rates. It has also been suggested that LAIs may help prevent white matter deterioration and other brain changes associated with disease progression, but this remains a hypothesis rather than a proven effect," Dr Poon clarifies.
Pharmaceutical manufacturers such as Johnson & Johnson (J&J), played a pivotal role by launching atypical antipsychotics such as risperidone in Malaysia, introducing a new era of serotonin-dopamine antagonists to the local healthcare system. In 2001, risperidone was included in the country’s drug formulary and became a standard treatment option across government healthcare facilities.
Lim Yee Pin, General Manager, Johnson & Johnson Malaysia and Indonesia says, “J&J made it our goal to help patients regain functionality so that they could reintegrate into society, return to work and live as contributing members of the community. By providing stable, consistent symptom control and reducing relapse rates, J&J’s therapies supported better long-term functioning, improved quality of life and greater treatment adherence for many individuals living with schizophrenia.”
Lived realities
Scientific advancements may have ushered in a new era of clinical care, but they do not always diminish the challenges of living with the illness as a patient or caregiver.
Nanny Eliana, a healthcare communications practitioner, shares her experience living with her biological father, a paranoid-schizophrenia patient. Adopted at two weeks old, she remained in contact with her biological family through her adoptive family until she was sent back to live with them at 17.
She learned that her biological father had been diagnosed with schizophrenia about 10 years before her return, following an incident in which he threw a rock at a parked car, believing he had seen a demon sitting on it. She explains, “He had been taking antipsychotic medication since his diagnosis and his condition had been stable enough for him to work part-time as a cleaner at a nearby coffee shop.”
However, after she moved in, his symptoms began to resurface, "On one occasion, I was alone at home with him when he charged at me with a knife. I managed to escape into a bedroom and lock the door. Another time, as I was returning home from school, he suddenly got up from the sofa next to the front door and repeatedly punched me in the face."
Nanny’s account highlights the vicious cycle of medication non-adherence and its side effects. “The attacks and outbursts escalated whenever he stopped taking his pills. After each outburst or attack, my mother and elder sisters would scold him and threaten to have him institutionalised. They would ensure that he resumed taking his medication, and things would settle down for a while. However, the medication also caused him to be in an almost zombie-like state, which may have been why he was reluctant to take it consistently,” she reflects.
Dr Poon confirms that this is common, “One of the biggest challenges in schizophrenia care is the cognitive impairment in over 80% of patients on antipsychotics, as well as persistent negative symptoms that affect about 40% of patients without any approved pharmacological treatment."
When asked why her father was not institutionalised despite his increasingly harmful behaviour towards her, Nanny explains, "His psychiatrist had advised the family to continue caring for him at home. The concern was that institutionalisation would isolate him from his family and the routines of everyday life, potentially exacerbating his condition and/ or triggering a recurrence of his symptoms."
Modernizing care
In the 2000s, Malaysia and Singapore made strides toward modernising their schizophrenia care standards, transitioning away from institutionalising patients and moving towards evidence-based and community-oriented care.
Singapore introduced its first dedicated MOH Clinical Practice Guidelines for Schizophrenia in 2003, standardising evidence-based treatment for acute symptoms and long-term management. Two years earlier, in 2001, the Early Psychosis Intervention Programme (EPIP) was launched to address prolonged delays in treatment, with patients experiencing a median duration of untreated psychosis (DUP) of 12 months between the onset of psychotic symptoms and initiation of appropriate treatment.
“A longer DUP is consistently associated with worse outcomes; more severe symptoms both negative and positive, poorer functioning, and lower chances of remission. Crucially, people with a DUP of less than nine months show substantially greater improvement in negative symptoms than those with longer DUP,” shares Dr Poon.
EPIP actively reduced DUP through targeted screening and specialised clinical case managers. It became part of the National Mental Health Blueprint in 2007 and later expanded to people at risk through a dedicated at-risk mental state programme.
The Clinical High-Risk for Psychosis (CHR-P) framework was developed to identify early changes that may precede a psychotic disorder. These include three clinical presentations: mild psychotic-like experiences, such as fleeting suspicious thoughts or unusual perceptions; subtle changes in thinking or perception that individuals can recognise and describe; and genetic vulnerability, such as having a first-degree relative with psychosis, accompanied by a significant decline in daily functioning.
Coordinated Specialty Care (CSC) is currently the gold standard for first-episode psychosis, focusing on a comprehensive, evidence-based, recovery-oriented, team-based model that promotes easy access to care and shared decision-making among specialists, the patient, and family members.
“Singapore’s EPIP is one of the earliest national CSC programmes in Asia. Mobilised locally for over two decades, EPIP has been subsequently extended to include an upstream programme targeting at-risk mental states as well as community youth mental health programmes, reflecting the evolution toward earlier and more proactive intervention,” adds Dr Poon.
Malaysia passed the Mental Health Act (2001) to establish legal procedures for the admission, detention, care, treatment and rehabilitation of individuals with mental disorders, as well as the Malaysian Mental Health Framework (2002) with the objective of shifting care away from isolated asylums towards primary care and community-based support. To reduce DUP, Malaysia aims to integrate standard Early Intervention in Psychosis (EIP) protocols into primary healthcare clinics.
A hopeful future
Regionally, Hong Kong has established itself as a leader in schizophrenia and psychosis care through several pioneering clinical shifts, most notably the Early Assessment Service for Young People with Psychosis (EASY Program).
The landmark mental health initiative launched in 2001 shows that 67.6% of EASY patients achieved a favourable employment trajectory over 10 years, compared to just 52.4% under standard care. This suggests that early, public-system intervention does not just manage acute hospital admission rates; it can change the trajectory of patients’ working lives on a large scale.
One of the features of decentralising community-based psychiatric care in Malaysia is the national expansion of the MENTARI community network, which scales up supported employment models to help patients regain financial independence and full functional recovery.
However, progress towards community-based care must be matched by access to appropriate treatment. The cost and limited availability of second-generation antipsychotics may restrict treatment options, potentially undermining efforts to achieve sustained recovery and improve patients’ daily functioning.
Looking ahead, the field of psychiatry aims to leverage emerging technology, such as neuroimaging, and blood-based biomarkers to predict the risk of mental health illness. However, until such a time when these technologies are available, schizophrenia care relies on what remains proven: early intervention, prioritising the patient's ability to function when treating them, and providing integrated support beyond the healthcare setting.
Comments