1 00:00:01,650 --> 00:00:06,630 Welcome to the Oxford University Psychiatry podcast series, 2 00:00:06,630 --> 00:00:13,980 you're here with Daniel Maun and Charlotte Allen, both advanced trainees in Oxford Deanery. 3 00:00:13,980 --> 00:00:17,610 Today we're going to be talking about schizophrenia. 4 00:00:17,610 --> 00:00:24,720 This is a very important condition in psychiatry and is one that sometimes difficult to understand, 5 00:00:24,720 --> 00:00:35,250 especially for students first starting out in the discipline. So, Daniel, maybe we could begin by asking what the word schizophrenia actually means. 6 00:00:35,250 --> 00:00:43,140 Schizophrenia actually means split mind, but importantly, it doesn't mean split personality. 7 00:00:43,140 --> 00:00:48,390 Often people equate schizophrenia diagnosis with a Jekyll and Hyde type of presentation. 8 00:00:48,390 --> 00:00:58,770 But this is actually quite far off from the truth. The term schizophrenia was first coined by Bleuler in 1988 and was intended to describe 9 00:00:58,770 --> 00:01:06,240 the separation or splitting of the different functions of the mind between personality, 10 00:01:06,240 --> 00:01:10,670 thinking, memory and perception. 11 00:01:10,670 --> 00:01:22,190 It sounds then that's like schizophrenia affects a huge number of different cognitive and mental functions, but can you say exactly what it is? 12 00:01:22,190 --> 00:01:26,540 Yes, you are right. It does affect lots of different cognitive functions. 13 00:01:26,540 --> 00:01:32,480 And I think the most important thing to realise is it is a serious mental illness. 14 00:01:32,480 --> 00:01:41,480 It's characterised by psychotic symptoms, including hallucinations, delusions and thought disorder. 15 00:01:41,480 --> 00:01:47,960 Schizophrenia affects a person's ability to distinguish between what's real and what's not real. 16 00:01:47,960 --> 00:01:53,270 As a result, they can begin to think, feel and behave in ways that are out of character from for them. 17 00:01:53,270 --> 00:01:56,540 And they can begin to develop beliefs that are not real. 18 00:01:56,540 --> 00:02:05,420 They can begin to experience things which aren't real, and their thoughts can become disjointed and confused at times. 19 00:02:05,420 --> 00:02:14,240 And as a result of all these different things going on, they can often become distressed or fearful, sometimes agitated. 20 00:02:14,240 --> 00:02:21,950 How common is it? Well, there's an overall lifetime risk of about one percent. 21 00:02:21,950 --> 00:02:27,290 The onset is characteristically between 15 and 45 years. 22 00:02:27,290 --> 00:02:40,940 Unlike men. Interestingly, women show a bimodal peak of incidence across the ages, with 10 percent of women having their first onset in middle age. 23 00:02:40,940 --> 00:02:49,340 There is a slight male preponderance, which is more pronounced in more severe forms as well. 24 00:02:49,340 --> 00:02:54,530 I think you've given us a good idea about what schizophrenia is overall. 25 00:02:54,530 --> 00:03:00,380 Can you tell us a little bit about the symptoms of schizophrenia? 26 00:03:00,380 --> 00:03:06,710 Yes, the symptoms can be grouped into two main categories positive and negative symptoms. 27 00:03:06,710 --> 00:03:14,520 Positive symptoms are called positive because they don't appear normal in the general population. 28 00:03:14,520 --> 00:03:22,410 But they are present in those with schizophrenia, these include hallucinations and delusions, 29 00:03:22,410 --> 00:03:31,530 negative symptoms are deficits of normal function, such as reduced emotional responses or confused thought processes. 30 00:03:31,530 --> 00:03:37,740 Other negative symptoms include social withdrawal or poor motivation as well. 31 00:03:37,740 --> 00:03:42,900 And can you say anything about what causes schizophrenia? 32 00:03:42,900 --> 00:03:52,620 Well, the causes are multifactorial and include genetics, life stressors, obstetric complications, drug and alcohol use. 33 00:03:52,620 --> 00:04:02,670 There are many different causes and it can be quite hard in any given individual to really pinpoint what the causes might be. 34 00:04:02,670 --> 00:04:09,330 You mentioned genetics that if there is schizophrenia, a heritable condition, it is a heritable condition. 35 00:04:09,330 --> 00:04:14,580 But due to the genetic contribution to the condition, it's more accurate, actually, 36 00:04:14,580 --> 00:04:20,790 to say that a person inherits the vulnerability of developing the condition rather than the condition itself. 37 00:04:20,790 --> 00:04:30,060 In other words, schizophrenia might develop due to the cumulative effects of several gene polymorphisms, 38 00:04:30,060 --> 00:04:35,040 although it should be noted that those with schizophrenia are genetically 39 00:04:35,040 --> 00:04:44,120 heterogeneous group and it's likely that both genetic and non genetic forms exist. 40 00:04:44,120 --> 00:04:48,900 OK, you also mentioned drug and alcohol use. 41 00:04:48,900 --> 00:04:54,210 Can you tell me a bit more about the contribution of substance misuse to schizophrenia? 42 00:04:54,210 --> 00:04:59,490 Well, it's widely accepted that psychoactive drugs such as amphetamines, cannabis, 43 00:04:59,490 --> 00:05:08,940 LSD and ketamine can provoke psychotic symptoms in both those with schizophrenia and actually healthy controls. 44 00:05:08,940 --> 00:05:17,880 There was a well-known, large, large cohort study in Sweden of actually of them of their military conscripts. 45 00:05:17,880 --> 00:05:30,600 And they found that cannabis intake at 18 years of age was associated with an increased risk of late psychosis with a relative risk of 2.5. 46 00:05:30,600 --> 00:05:37,650 And interestingly, this list increased six fold risk for heavy users. 47 00:05:37,650 --> 00:05:46,600 So that study is quite well known because it shows a dose related effect and is accepted. 48 00:05:46,600 --> 00:05:52,350 The cannabis clearly does increase the risk, but its impact on the development of schizophrenia. 49 00:05:52,350 --> 00:05:56,430 Some say now is not as great as previously feared. 50 00:05:56,430 --> 00:06:03,390 OK, so there's some evidence that it might increase the risk, but it's not necessarily going to lead to schizophrenia. 51 00:06:03,390 --> 00:06:10,200 That's right. Are there any other risk factors that might contribute to the development of schizophrenia? 52 00:06:10,200 --> 00:06:18,570 In theory, any environmental stressor or significant life event can trigger the development of schizophrenia. 53 00:06:18,570 --> 00:06:28,860 Factors such as social adversity, social isolation, migrant status, and, in fact, urban life as well. 54 00:06:28,860 --> 00:06:34,410 There are many different factors that are associated with an increased risk. 55 00:06:34,410 --> 00:06:43,920 In the past, schizophrenia was known as a functional illness because it was thought that there were no actual changes in the brain. 56 00:06:43,920 --> 00:06:49,500 But I know that now we've got a lot more advanced tools to investigate brain structure, things like neuroimaging. 57 00:06:49,500 --> 00:06:55,500 And I just wondered if you could say anything more about the structure of brain abnormalities that are found in schizophrenia. 58 00:06:55,500 --> 00:07:01,950 Yes, there have been many studies that use structural imaging techniques such as CTE or 59 00:07:01,950 --> 00:07:08,670 MRI scanning that are so consistent abnormalities in people with schizophrenia, 60 00:07:08,670 --> 00:07:12,960 including decreased brain volume, particularly in the frontal and temporal lobes, 61 00:07:12,960 --> 00:07:20,400 thalamus and white matter tracks in large third natural ventricles is a common finding. 62 00:07:20,400 --> 00:07:29,370 Smaller medial temporal lobes, decreased cortical grey matter and reduced cerebral asymmetry, a rather common findings. 63 00:07:29,370 --> 00:07:33,930 It sounds like there are quite a lot of macro structural changes. 64 00:07:33,930 --> 00:07:37,500 Then how about on the micro structural level? 65 00:07:37,500 --> 00:07:44,370 Is there any evidence to suggest that there's anything going wrong in terms of neurochemicals in the brain? 66 00:07:44,370 --> 00:07:49,710 Yes, the main neurochemical implemented in schizophrenia is don't. 67 00:07:49,710 --> 00:07:59,310 For me, this was originally actually due to the accidental finding that Fener thiazide drugs which blocked dopamine function, 68 00:07:59,310 --> 00:08:06,750 reduce psychotic symptoms. Another factor which supports this don't mean hypothesis is that amphetamines, 69 00:08:06,750 --> 00:08:12,690 which trigger the release of data mean can induce psychotic symptoms and help individuals and those in schizophrenia. 70 00:08:12,690 --> 00:08:21,120 As I mentioned earlier, in addition to this, all antipsychotic drugs don't mean receptor antagonists. 71 00:08:21,120 --> 00:08:28,380 And or at least interact with the domain in a modulated fashion, as some of the modern drugs do, 72 00:08:28,380 --> 00:08:38,370 and there's been a good study showing that affinity with the D2 receptor correlates with clinical potency of medication. 73 00:08:38,370 --> 00:08:43,470 It sounds like dopamine is then a very important chemical in schizophrenia. 74 00:08:43,470 --> 00:08:49,230 Are there any others that are also important? Yes. More recently, glutamate has been found to be involved, 75 00:08:49,230 --> 00:08:57,900 in particular the NMDA glutamate receptor antagonist of this NMDA receptor, such as ketamine or fennel. 76 00:08:57,900 --> 00:09:06,210 Claudine or PCP, as it's more commonly known, can induce a schizophrenia like psychosis. 77 00:09:06,210 --> 00:09:15,210 How would you actually go about diagnosing schizophrenia? Well, I think it's best that we focus on the subtype of paranoid schizophrenia here. 78 00:09:15,210 --> 00:09:21,120 There are other subtypes, including apophatic and catatonic, but these are much less common. 79 00:09:21,120 --> 00:09:24,150 OK, so we'll focus on paranoid schizophrenia for today. 80 00:09:24,150 --> 00:09:35,070 OK, so if we use the World Health Organisation's ICD 10 diagnostic criteria, then you would need specific symptoms for at least one month. 81 00:09:35,070 --> 00:09:43,200 This is opposed to the American DSM system where you would need symptoms for at least six months for a diagnosis. 82 00:09:43,200 --> 00:09:49,530 So taking the World Health Organisation, the ICD 10 criteria, which is what we use here in the UK, 83 00:09:49,530 --> 00:09:55,830 you need either one primary symptom or two secondary symptoms for at least one month. 84 00:09:55,830 --> 00:10:07,500 And what are the primary symptoms? Primary symptoms include Sawako thought insertion for withdrawal and thought broadcast. 85 00:10:07,500 --> 00:10:19,470 Can you explain what these are? Well, first of all, dealing with thought echo, this is the perception that your thoughts are being heard out loud. 86 00:10:19,470 --> 00:10:23,130 So that's actually a hallucination. Moving on to thought insertion, 87 00:10:23,130 --> 00:10:32,550 withdrawal and broadcast for insertion is the belief that somebody else or something else is inserting thoughts in your head. 88 00:10:32,550 --> 00:10:39,540 Thought withdrawal is the belief that somebody or something is taking thoughts out of your head and thought 89 00:10:39,540 --> 00:10:48,350 broadcast is the belief that your thoughts are being broadcast a bit like a radio into other people's heads. 90 00:10:48,350 --> 00:10:52,950 OK. And are there any other primary symptoms? Yes, there's there's quite a list. 91 00:10:52,950 --> 00:10:58,920 The next there's delusions of control, influence or passivity. 92 00:10:58,920 --> 00:11:07,480 These are beliefs that somehow you are being affected by an external agency or someone else. 93 00:11:07,480 --> 00:11:14,610 So you believe that you're being controlled, your movements are being controlled, your thoughts are being controlled, 94 00:11:14,610 --> 00:11:23,460 your emotions are being controlled somehow, maybe telepathically or by some other method. 95 00:11:23,460 --> 00:11:29,550 Are there any other symptoms? Yes, delusional perception is the primary symptom. 96 00:11:29,550 --> 00:11:38,640 And this is an interesting symptom which is thought to occur at the onset of a psychotic episode where it is 97 00:11:38,640 --> 00:11:45,660 you have it a normal perception that's followed by a delusional interpretation of that normal perception. 98 00:11:45,660 --> 00:11:53,010 Can you give me an example of delusional perception? An example of this might be seeing a red car, for instance, 99 00:11:53,010 --> 00:12:01,230 walking down the street when you walk down the street and then come to believe that seeing red car means that you're being followed by the MiFi, 100 00:12:01,230 --> 00:12:06,960 for instance, we've covered quite a number of primary symptoms. 101 00:12:06,960 --> 00:12:08,130 I'll just run through them. 102 00:12:08,130 --> 00:12:19,790 So it's thought I go in session withdrawal or broadcast also delusions of control, influence or passivity and delusional perception. 103 00:12:19,790 --> 00:12:23,910 Are there any other primary symptoms? Yes, there are this. 104 00:12:23,910 --> 00:12:37,170 This group hears about hallucinations. There are specific hallucinations which are auditory and they are quite specific and they're for schizophrenia. 105 00:12:37,170 --> 00:12:45,690 And they include hallucinatory voices giving running commentary of what the person is doing in a given moment. 106 00:12:45,690 --> 00:12:55,200 So, for instance, talking about the fact that cooking dinner and making ourselves a cup of tea and then sitting down watching TV. 107 00:12:55,200 --> 00:13:02,820 So it's running commentary. Another example of a hallucination, it's primary symptom is third person hallucinations, 108 00:13:02,820 --> 00:13:07,170 which is when a number of different voices are talking about the patient. 109 00:13:07,170 --> 00:13:15,390 And the last primary symptom, which is a hallucination, is that of a voice coming from another part of their body. 110 00:13:15,390 --> 00:13:20,260 For instance, their little toe is speaking to them. 111 00:13:20,260 --> 00:13:27,190 Are there any other primary symptoms or have we covered them on the last one is a persistent delusion 112 00:13:27,190 --> 00:13:33,190 which is culturally inappropriate or impossible and classically has a bizarre nature to it. 113 00:13:33,190 --> 00:13:37,240 You say classically it has a bizarre content, but I suppose, of course, 114 00:13:37,240 --> 00:13:43,360 it might be a fairly ordinary content and that might make it quite difficult to detect. 115 00:13:43,360 --> 00:13:57,100 Yes. For instance, the fact that I might be going out with the Queen is theoretically possible and therefore not a primary symptom. 116 00:13:57,100 --> 00:14:09,460 The fact that I might be the Queen is impossible and therefore is a primary symptom if it is persistent and culturally inappropriate. 117 00:14:09,460 --> 00:14:15,760 Thanks. What about the secondary symptoms? Can you tell me what those are? 118 00:14:15,760 --> 00:14:22,090 Yes. Secondary symptoms start with persistent hallucinations of any modality within any sense. 119 00:14:22,090 --> 00:14:35,260 For instance, an olfactory or smell or visual hallucination, for instance, which is accompanied by fleeting or harmful delusion thought disorder, 120 00:14:35,260 --> 00:14:46,060 which is well present, says incoherent or irrelevant speech, but can often be experienced confusion by the patient, 121 00:14:46,060 --> 00:14:58,960 catatonic behaviour, which is a disturbance of psychomotor function and actually can be observed in a variety of disorders and negative symptoms, 122 00:14:58,960 --> 00:15:05,700 including apathy, blunting of emotions and social withdrawal. 123 00:15:05,700 --> 00:15:11,040 Can you say a little bit about the prognosis of schizophrenia? 124 00:15:11,040 --> 00:15:18,930 Yes, schizophrenia is a major cause of disability. And although most people with schizophrenia live independently, 125 00:15:18,930 --> 00:15:25,380 they do often require some degree of ongoing management for mental health services and community support services. 126 00:15:25,380 --> 00:15:34,140 People having a first episode of psychosis roughly have a one in three chance of a good long term outcome with no further episodes. 127 00:15:34,140 --> 00:15:36,840 Another third tend to have a relapsing remitting course, 128 00:15:36,840 --> 00:15:44,240 and roughly the last third of a percent have more of a poor outcome with some ongoing residual symptoms. 129 00:15:44,240 --> 00:15:49,620 Are the factors that affect prognosis include response to antipsychotic medication, 130 00:15:49,620 --> 00:15:59,330 ongoing drug use or life stresses, and frequent exposure to situations with a high expressed emotional content? 131 00:15:59,330 --> 00:16:05,280 Can you say what you mean by that? Yes, it's really important to have a low stimulus environment. 132 00:16:05,280 --> 00:16:14,160 It's important that patients who have schizophrenia aren't exposed to, for instance, 133 00:16:14,160 --> 00:16:22,710 difficult arguments or fights or situations with a high emotional content. 134 00:16:22,710 --> 00:16:29,640 Does that make sense? Yeah, I think that yes. Does schizophrenia affect life expectancy? 135 00:16:29,640 --> 00:16:36,120 Yes. Schizophrenia does result in a decreased life expectancy of between 12 and 15 years. 136 00:16:36,120 --> 00:16:45,010 And although this is primarily because of its association with obesity and sedentary lifestyles and smoking, 137 00:16:45,010 --> 00:16:49,890 suicides also plays a role in increasing the risk, 138 00:16:49,890 --> 00:16:57,510 although not as much as with bipolar disorder, people with schizophrenia have an increased risk of cardiovascular disease. 139 00:16:57,510 --> 00:17:02,580 And that's why promoting good fiscal health is really important and being aware of the 140 00:17:02,580 --> 00:17:08,470 risks associated with some of the long term antipsychotic medication we give patients. 141 00:17:08,470 --> 00:17:13,260 Because of these factors, it's really important that metabolic monitoring such as fasting, 142 00:17:13,260 --> 00:17:20,370 lipids, glucose amongst all the blood tests should be performed every three to six months. 143 00:17:20,370 --> 00:17:26,580 Can you actually cure schizophrenia? Well, no, you can't. 144 00:17:26,580 --> 00:17:31,740 But there are effective treatments that can significantly improve symptoms. 145 00:17:31,740 --> 00:17:38,850 The most suitable paradigm potentially for think about management of schizophrenia is that of chronic disease management. 146 00:17:38,850 --> 00:17:43,950 It's a bit like managing diabetes in a way. You can't cure diabetes, but you can you can. 147 00:17:43,950 --> 00:17:47,970 You manage it very effectively. It's an ongoing condition. 148 00:17:47,970 --> 00:17:58,130 Schizophrenia requires long term medication and lifestyle modification, but with the correct package, the person can do very well. 149 00:17:58,130 --> 00:18:05,180 It's good to have an encouraging message. I think it is a condition which can be very difficult, can be very disabling. 150 00:18:05,180 --> 00:18:11,240 So it's good to know that with the right support, people can live well. 151 00:18:11,240 --> 00:18:18,770 Could you say a little bit more about the management? And first, tell me a bit about the pharmacological management. 152 00:18:18,770 --> 00:18:24,530 The mainstay of treatment pharmacologically is antipsychotic medication. 153 00:18:24,530 --> 00:18:33,410 Those, interestingly, little evidence for any difference in the efficacy and effectiveness of the different antipsychotics. 154 00:18:33,410 --> 00:18:36,980 We talk about first generation and second generation antipsychotics. 155 00:18:36,980 --> 00:18:45,410 A lot of actually the main way that they differ is not necessarily in their efficacy, but more in the different side effects that they give. 156 00:18:45,410 --> 00:18:48,680 So nosecone actually suggests that you should discuss with the patient what 157 00:18:48,680 --> 00:18:54,770 medication would most suit them by reviewing each medications side effect profile. 158 00:18:54,770 --> 00:19:05,900 Can we say what the side effects are with each of these groups of drugs? Yes, most antipsychotics do give you some level of sedation, 159 00:19:05,900 --> 00:19:11,570 but the two main groups of psychotics each have their own characteristic side effect profile. 160 00:19:11,570 --> 00:19:18,350 First generation antipsychotics such as Haloperidol, they have movement side effects. 161 00:19:18,350 --> 00:19:24,860 We call these extra pyramidal side effects. They're called experimental side effects because they affect the pathways in 162 00:19:24,860 --> 00:19:29,900 the brain and the spine to do with movement that are not the pyramidal tracts. 163 00:19:29,900 --> 00:19:37,550 And it's extra pyramidal and the second generation of psychotics such as olanzapine Oncotype End tend to 164 00:19:37,550 --> 00:19:46,940 cause more weight gain and tend to be more sedative again over and above the first generation of psychotics. 165 00:19:46,940 --> 00:19:52,190 What would happen if antipsychotic medication isn't effective? 166 00:19:52,190 --> 00:20:01,610 If a patient has been trialled on two antipsychotics at a reasonable dose for at least eight weeks and remains experiencing significant symptoms, 167 00:20:01,610 --> 00:20:13,710 then we would look to thinking about the medication called Klonopin, which has been proven to be effective in treatment resistant schizophrenia. 168 00:20:13,710 --> 00:20:21,080 What's been used is restricted because it has a serious side effect of causing a great deal of psychosis. 169 00:20:21,080 --> 00:20:26,630 So. We use clozapine and it's actually a very good medication, 170 00:20:26,630 --> 00:20:35,060 but we need to several types of monitoring before they start clozapine and then we need to monitor their full 171 00:20:35,060 --> 00:20:42,200 blood count every week for six months and then every other week for the year and then monthly thereafter, 172 00:20:42,200 --> 00:20:48,170 after we've tried clozapine, we would move towards different combinations of antipsychotics. 173 00:20:48,170 --> 00:20:55,580 But this really is best avoided if possible, given the risks associated with combinations of antipsychotic medications. 174 00:20:55,580 --> 00:21:04,160 And in this case, if we do use polypharmacy, then extra physical monitoring of the patient is required. 175 00:21:04,160 --> 00:21:08,510 Given some of the side effects associated with antipsychotics, 176 00:21:08,510 --> 00:21:15,800 with psychological therapies be appropriate for schizophrenia, yes, psychological treatments would be appropriate. 177 00:21:15,800 --> 00:21:24,440 But I think it's important to realise that patients do need to have pharmacological therapies that mainstay of treatment, 178 00:21:24,440 --> 00:21:30,980 psychological treatment would be seen as additional to the pharmacological intervention. 179 00:21:30,980 --> 00:21:40,250 And CBT can be used in schizophrenia and has been seen to help reduce anxiety and paranoia associated with chronic psychotic symptoms. 180 00:21:40,250 --> 00:21:44,300 So CBT is targeting the symptom of the psychotic symptoms, 181 00:21:44,300 --> 00:21:50,900 particularly in how patients experience those as a way of reducing the distress caused by them. 182 00:21:50,900 --> 00:21:58,130 That's right. CBT doesn't challenge the delusions necessarily or the experience of hallucinations. 183 00:21:58,130 --> 00:22:05,060 It rolls with the experiences the patient experience has and says, okay, well, 184 00:22:05,060 --> 00:22:11,380 if you do feel followed all the time, how can we help you with that belief? 185 00:22:11,380 --> 00:22:16,910 And other psychological treatment is family therapy, which, as I mentioned earlier, 186 00:22:16,910 --> 00:22:24,860 about high expressed emotions, family therapy as a specific intervention to try and reduce that. 187 00:22:24,860 --> 00:22:32,540 If I expressed emotions are present in a patient's family, it can seriously affect their prognosis. 188 00:22:32,540 --> 00:22:36,770 How about social interventions? Can they be helpful for schizophrenia? 189 00:22:36,770 --> 00:22:43,910 Well, yes. Social management should always be a fundamental part of a patient's care package. 190 00:22:43,910 --> 00:22:51,230 Schizophrenia can be socially isolating and can lead to difficulties in maintaining independence. 191 00:22:51,230 --> 00:22:58,130 And for that reason, a social worker can help sorting out their benefits and their housing, 192 00:22:58,130 --> 00:23:03,500 and occupational therapist can help structured activities and monitor safety in the home environment. 193 00:23:03,500 --> 00:23:14,120 And a support group can help with a patient's recovery as can ensure that the patient has adequate employment support and advice. 194 00:23:14,120 --> 00:23:20,360 Is there anything else that we should think about in terms of management? 195 00:23:20,360 --> 00:23:28,770 Well, the fact that the experience of being psychotic can be so very alarming and distressing, 196 00:23:28,770 --> 00:23:34,400 it can't that can lead to the patient posing a significant risk to themselves and others. 197 00:23:34,400 --> 00:23:43,610 And this alongside the frequent lack of insight that is associated with schizophrenia coming admission to hospital is required. 198 00:23:43,610 --> 00:23:50,210 It may also be that the Mental Health Act is needed to admit the patient against their will for assessment and treatment. 199 00:23:50,210 --> 00:23:53,840 But admission is usually reserved for those cases where community management 200 00:23:53,840 --> 00:24:00,860 has failed or the patient poses significant risks to themselves or others. 201 00:24:00,860 --> 00:24:06,140 Before we finish. Are there any final points that you'd like to make? 202 00:24:06,140 --> 00:24:11,690 Well, I think what mustn't be forgotten is that if the patient has a carer, 203 00:24:11,690 --> 00:24:22,580 then reviewing the carers needs is important as well as a psychotic illness can have a big impact on those closest to the patients. 204 00:24:22,580 --> 00:24:29,330 So in this case, the current assessment and referral to the care of support group can be very helpful. 205 00:24:29,330 --> 00:24:38,990 Thank you very much. That was a good overview, I think, of the causes of schizophrenia and also the approaches to treatment and management. 206 00:24:38,990 --> 00:24:44,136 I hope that's been useful for our listeners. Thank you very much.