Exploring Novel Therapies for Schizophrenia-Dementia Patients in Forensic Settings: Beyond Traditional Approaches

The population worldwide is ageing at a rapid pace and so are forensic detainees with severe psychiatric illnesses, including schizophrenia (SCZ) and schizophrenia-like disorders (SLDs). Forensic institutions throughout the world house patients with severe psychiatric illness and history of criminal violations. The primary objective of this study is to explore novel therapies for Schizophrenia-dementia patients in forensic settings. Improved medical care, hygiene, psychiatric treatment, and nutrition led to an unmatched longevity in this population, which previously lived, on average, 15 to 20 years shorter than the public at large. On the other hand, longevity has contributed to an increased prevalence of age-related diseases, including neurodegenerative disorders, which complicate clinical management, increasing healthcare expenditures. Forensic institutions, originally intended for the treatment of younger individuals, are ill-equipped for the growing number of older offenders. Moreover, as antipsychotic drugs became available in 1950s and 1960s, we are observing the first generation of forensic detainees who have aged on dopamine-blocking agents. Although the consequences of long-term treatment with these agents are unclear, schizophrenia-associated gray matter loss may contribute to the development of early dementia. Taken together, increased lifespan and the subsequent cognitive deficit observed in long-term forensic institutions raise questions and dilemmas unencountered by the previous generations of clinicians. These include: does the presence of neurocognitive dysfunction justify antipsychotic dose reduction or discontinuation despite a life-long history of schizophrenia and violent behavior? Should neurolipidomic interventions become the standard of care in elderly individuals with lifelong schizophrenia and dementia? Can patients with schizophrenia and dementia meet the Dusky standard to stand trial? Should neurocognitive disorders in the elderly with lifelong schizophrenia be treated differently than age-related neurodegeneration? In this article, we hypothesize that gray matter loss is the core symptom of schizophrenia which leads to dementia. We hypothesize further that strategies to delay or stop gray matter depletion would not only improve schizophrenia-sustained recovery, but also avert the development of major neurocognitive disorders in people living with schizophrenia. Based on this hypothesis, we suggest the utilization of both receptor-dependent and independent therapeutics for chronic psychosis. While acute psychosis responds very well to antipsychotic drugs, chronic psychotic illnesses are much more refractory to these agents. Over the past decades, psychopharmacology has focused excessively on the receptor-dependent actions of antipsychotic drugs and put much less emphasis on the receptor-independent ones, such as antimicrobial and anticancer actions.