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Treatment-Resistant Schizophrenia in Young Adulthood

Est. reading time: 6 mins
Posted Under: Insights, Interviews, Treatment Insights

Clinically Reviewed by: Amanda Fialk, PhD, LCSW, LICSW

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This post was developed based on a continuing education event hosted by The Dorm with Rocco Marotta, MD, PhD, Director of the Center for the Treatment and Study of Neuropsychiatric Disorders at Silver Hill Hospital.


Schizophrenia is a complex, chronic, and frustrating mental illness that most notably involves psychosis, hallucinations, and delusions. It is a developmental disorder and brain disease that often arises in the young adult years, which is why it’s of significant interest to our clinicians at The Dorm, a treatment community serving young adults ages 18-30. 

We recently welcomed Dr. Rocco Marotta, Director of the Center for the Treatment and Study of Neuropsychiatric Disorders at Silver Hill Hospital, who joined us for an educational presentation exploring treatment-resistant schizophrenia, which impacts over a third of individuals with schizophrenia. Clients experiencing treatment-resistant schizophrenia continue to experience symptoms despite multiple trials of antipsychotic medications. 

In the following blog post, we summarize how even “treatment-resistant” disorders can be improved with various interventions, giving hope to impacted individuals, their families, and their communities.

With Dr. Marotta’s expert input, we will explore why symptoms of schizophrenia may be increasing for young adults in recent years, and review a multi-prong approach to treatment that includes medication, therapy, and support from family and community. 

Key Article Takeaways: 

Schizophrenia is characterized by “positive” symptoms, “negative” symptoms, and cognitive impairment.

Clinicians have historically focused on treating “positive symptoms” like psychosis through medication with varying results – unfortunately over a third of cases continue to experience debilitating symptoms.

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Dr. Marotta calls for a “5 Pillar” Treatment approach, involving sobriety, community, trust, medication compliance, and family support, and structural changes.

What is Schizophrenia?

For a primer on schizophrenia, Dr. Marotta walked us through the DSM’s current definition of schizophrenia: a chronic mental illness with positive symptoms, negative symptoms, and cognitive impairment. 

Positive Symptoms

Positive symptoms are defined as symptoms that are abnormally present in individuals with psychosis and can include:

  • Hallucinations (hearing voices or seeing things that do not exist)
  • Delusions and paranoia
  • Distorted or exaggerated perceptions, beliefs, and behaviors

Negative Symptoms

Negative symptoms are defined as thoughts and behaviors present in populations without psychosis that are absent in individuals with psychosis and can include:

  • Lack of motivation 
  • Lack of social connection
  • Decrease in the ability to initiate plans, express emotion, etc.

Cognitive Impairment

Cognitive impairment symptoms include:

  • Deficits in quality of life
  • Deficits in educational attainment
  • Deficits in IQ

What Makes Schizophrenia So Resistant to Treatment?

The primary reason schizophrenia is so difficult to treat is that clinicians don’t yet understand the underlying neurobiology of schizophrenia, Dr. Marotta notes. It is a complex mental illness which is most likely a combination of several overlapping disorders.  

Medication isn’t Enough

Dr. Marotta also emphasized that historically we’ve focused on treating mostly the “positive” symptoms of schizophrenia, such as psychosis, delusions, and paranoia, but have been unable to make as much progress with the underlying “negative” symptoms, including a lack of social connection and decreased ability to initiate plans, express emotion, or sustain productive relationships. 

“Most of the treatment over the last fifty or sixty years has been focused on medication treatments,” he explained. “The real bread and butter of it, for saving people’s lives, communities, and thus societies, is not just getting the overt (positive) symptoms under control, but doing something about the withdrawn, “negative” symptoms and impacting cognition, which has not been an easy thing to do.”

Structural Inequities

Additionally, Dr. Marotta notes that up to 1% of Americans experience schizophrenia and emphasizes the need for structural changes in our society to make treatment more equitable. Furthermore, based on recent research, he believes that the rate of this disorder has been increasing in recent years primarily as the result of more potent drugs that are available, including cannabis.

Rising Rates Substance Use and Cannabis Use Disorders

Studies have shown that the rates of schizophrenia have been rising in recent years, and some professionals believe this is a result of an increase in cannabis use and potency. For example, he cited a Danish study that suggested that 15% of cases of schizophrenia in males “may have been prevented” if cannabis-use disorder in those individuals had not been present. 

More general statistics from recent years show just how prevalent psychosis is in our society: 

These additional cases are an enormous burden on the healthcare system as a whole as well as the individuals affected, their families, and their communities. 

The Five Pillars of Schizophrenia Treatment

Fortunately, today we have a variety of care options for clients with psychosis, schizophrenia, or treatment-resistant schizophrenia. According to the World Health Organization, at least one in three people with schizophrenia will be able to fully recover

Patients recovering from schizophrenia can’t do it alone, however. As Dr. Marotta notes, “Schizophrenia is a biological, psychological, and social disease,” which involves multiple support systems in place. “Medications may be necessary, but they’re not sufficient for treatment,” explains Dr. Marotta. 

Ultimately, support from family and community plays a critical role in the success of treatment for schizophrenic patients. He summarizes five main pillars of schizophrenia treatment:

  1. Sobriety 
  2. Medication management & compliance
  3. Trust between the patient, their family, and their healthcare providers
  4. Ability to maintain social connectedness
  5. Availability of lasting professional and family support

These pillars of schizophrenia treatment are vital to helping an individual lessen their most debilitating symptoms, as well as help them grow and maintain practices that could further improve their daily functioning over long periods (years, not months).

Exploring Sobriety & Social Connectedness 

As with all mental health concerns, we see better treatment results when a client is sober from drugs and alcohol. However, for young adult clients, this can be a serious barrier to care. 

“In our current world, sobriety is an issue,” says Dr. Marotta. “If we believe that cannabis and alcohol will worsen psychosis, but they are available on every street and dormitory, then we have a problem.” 

He goes on to ask: For clients whose social networks have emerged in these environments, how do you get young adults to sustain contact with their treatment teams and communities that will help them heal over a sustained period? 

In short, clients recovering from schizophrenia will need long-term sober communities in place that will give them belonging and a sense of purpose. Dr. Marotta praised Alcoholics Anonymous as a form of “spiritual intervention” that serves as a powerful community-building tool for many individuals recovering from symptoms of schizophrenia.

Understanding Medication Support for Schizophrenia Treatment

It is not possible to treat schizophrenia with medication alone. However, medication can be very effective when paired with social support and a communal framework, explains Dr. Marotta. From a pharmacological standpoint, the traditional medications for schizophrenia are dopamine blockers, as one of the theories about the presentation of schizophrenia is that it is caused by an excess of dopamine. 

Dr. Marotta identifies Clozapine as a helpful option for medication for treatment-resistant patients with schizophrenia who haven’t benefited from two adequate trials of other antipsychotics. It reduces aggression, irritability, and suicidality and it controls positive symptoms.

Additionally, compared to other pharmacological options, it has a much higher rate of helping negative symptoms, as well as possible improvement of cognitive abilities. However, clozapine comes with some serious side effects and requires careful oversight and control. 

Fortunately, today, professionals like Dr. Marotta and researchers continue to measure and track the effectiveness of the future of medications for schizophrenia with some promising results for medication as part of a comprehensive treatment strategy. Dr. Marotta believes complex pharmacological interventions are often necessary.  These may include mood stabilizing antiepileptic drugs like Lamictal, and a neuropeptide like oxytocin (which helps alleviate autistic symptoms and anxiety and may foster social connectedness). Under special circumstances (e.g. returning to college and work), even the use of mild stimulants like Nuvigil can be helpful.  He also believes that every patient must be treated as a unique case and that the particular symptom constellation of that patient has to be carefully addressed. Additionally, clinicians should always take any negative side effects seriously.

Finding Lasting Support for Schizophrenia Treatment

Ongoing Therapeutic Support

Because schizophrenia is a chronic illness, clients should seek ongoing professional interventions in addition to their psychiatric support and medication regime. Clinical therapies that have been shown to help improve symptoms include individual therapy, group therapy, family therapy, and cognitive behavioral therapy (CBT). Social skills therapy is also a useful tool for clients whose cognition has been impaired. 

Above all, clients should find a therapeutic professional that they trust and respect since this improves treatment outcomes. 

Family Therapy & Community Support

Finally, Dr. Marotta cites family therapy as a critical key to recovery. However, “families need support so they can help their family members,” he said. Beyond treatment, organizations including the Schizophrenia Alliance and the National Alliance for Mental Illness (NAMI) provide useful groups for families ready to design a network that works for them in the long term. 

In conclusion, we’d like to thank Dr. Rocco Marotta for his enormous contribution to the field when it comes to understanding treatment-resistant schizophrenia, the nuances of medication management, and the current state of psychosis for young adults today.

Learn more about Silver Hill Hospital’s work with Schizophrenia treatment.


At The Dorm, we provide holistic intensive outpatient treatment services for young adults ages 18-30. For clients recovering from symptoms of schizophrenia, our team collaborates with consulting psychiatrists and outside providers to make sure clients get the wrap-around care they need. Please email us at hello@thedorm.com to get in touch with any questions. 

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