In the past, the typical approach of a psychiatrist to a patient with schizophrenia would be to ‘fix the problem’, that is what physicians are trained to do. So if we give the patient an antipsychotic, their primary symptoms will be gone, and it is tempting to consider the problem solved. However, we need to look beyond remission of the patient’s symptoms, to the long-term goal allowing the patient to function in the world – having relationships, working, playing a role in the community. This takes time to establish (at least 12 months after an acute episode of psychosis) and contact with the patient to assess how they are.
One of the most challenging things I teach to young doctors is ‘talk to your patient’. This is a simple (but time-consuming) intervention that gives us a great deal of information. So ask the patient to describe a typical day for you, or when did they last meet a person outside their home, or when did they last read a newspaper, and what did it say? We don’t typically ask patients these sorts of questions, but they give us a great gauge on their QoL and ability to function.
The outcomes that matter to patients, in terms of their ability to function, are often really basic things: are they experiencing dizziness or tiredness, sexual dysfunction, or an inability to concentrate as a side-effect of their treatment? All of these would make day-to-day living and relationships difficult to sustain. If a person is too tired to stay awake, too dizzy to move around, unable to concentrate on and therefore follow a conversation, or unable to have sex, both their QoL and functioning will be profoundly damaged. So we need to ask patients about these things, even when it seems difficult to introduce the question, as we will get some insight into what life is like for them, and their priorities for treatment.
When thinking about treating patients with schizophrenia, there are subgroups whose disease course will be different in the long term. For about 20% of patients, they will have one or two episodes of psychosis, but then experience recovery and not need further treatment. Another group of patients will have occasional relapses, but not have residual symptomatology, so they experience a satisfactory outcome from treatment. The patients who are difficult to treat in the long term are those approximately 50% who have frequent relapses (possibly yearly) that lead to an accumulation of residual symptoms. Over time, these patients find normal life stressors increasingly overwhelming, so have a poor QoL and functioning, along with an unfavourable disease prognosis. In these patients it is very important to do everything we can to prevent these repeated relapses and deterioration. They need a comprehensive programme of treatment, with pharmacotherapy, psychotherapy for both the patient and family, supported employment and psychosocial interventions. It is possible to identify patients with residual symptomatology early in their disease course, and ideally we need to introduce comprehensive treatment within the first 2 years of disease onset, before there has been too much loss of function and detrimental brain changes.
In those patients who might well benefit from comprehensive management early in their disease course to prevent relapses, the long-acting injectable antipsychotics are a good treatment option. I believe that psychiatrists need to impress upon patients the seriousness of their condition, and the need to treat it rapidly and consistently to avoid psychosocial disability in the long-term. So we should consider atypical LAIs early in the disease course, to provide this efficacy and consistency of disease management. It is also important that the prescribing psychiatrist sees the patient at each appointment for injection of their LAI – the patient does not just meet with the nurse. This gives the psychiatrist an opportunity, even if only for a short time, to monitor the patient’s side-effects, to see how they look from one appointment to the next, and to ask them how they are and what they are doing.
Above all: speak to the patient.