Dr Kane spoke on current treatment options at a satellite symposium on functioning and quality of life (QoL) as long-term treatment goals in schizophrenia. Afterwards, our correspondent spoke with him to hear more of his views on current treatments and patient outcomes.
Psychiatrists need to increase their focus on these important aspects of the disease. Until now, their attention has mainly been directed towards managing the key signs and symptoms of schizophrenia. However, for patients and their families, a good QoL, functioning and leading a normal life are extremely important. By ‘normal life’ I mean patients being engaged in the community, having relationships, and being able to go to work or school – patients need help in achieving these goals. They need to be taking the best medicine for them, to be helped to continue taking it, and to be offered psychosocial interventions to support them in this process.
The things that are most important to patients are social relationships, having a job, a place to live, an intimate relationship, and hobbies. Like any person, patients want to feel connected to others, that they belong in their families and communities, and that they are living their life in a meaningful way – this is what anyone would want.
Outcomes currently leave a lot to be desired. Only about 14% of patients with schizophrenia achieve what we would call a recovery and are able to achieve all the sorts of goals we have been talking about above. A primary driver for the clinician is to address the symptoms that first brought the patient into the healthcare system, for example, agitation and aggression. These are obviously symptoms to manage, but treatment strategies for these acute problems are not necessarily the most useful for long-term overall management of the patient’s condition. Moreover, in the community patients are often not getting all the help they need to improve their functioning and QoL. Physicians are trained to help solve medical problems, but they also need to work with colleagues to ensure that their patients get access to and benefit from psychosocial interventions. These are often needed to help manage the patient’s physical health and well being, their lifestyle, avoid substance abuse, stop smoking etc. Otherwise schizophrenia takes a large toll on patients: chronic and severe mental health issues can reduce a patient’s life expectancy by 15 years.
The importance of medication in managing schizophrenia has been demonstrated beyond doubt. However, understandably, people do have problems taking oral medication in the long-term. So long-acting drugs offer the option for patients to receive their treatment at less frequent intervals, which also allows us to maintain contact with the patient, and undertake other psychosocial interventions over a long period of time.
Use it, use it and use it! These drugs are currently under-utilised. So work with patients; spend the time to understand why they may be reluctant to try these treatments, and work out how to present this treatment option to the patient in a way that will appeal to them. Working with patients in using LAIs is a process that takes time, so don’t give up too quickly. If the psychiatrist and the patient work together within a good therapeutic alliance, they can both take steps to prevent relapses and optimise the patient’s long-term outcomes.
An interview with Dr John M. Kane, The Zucker Hillside Hospital, Glen Oaks, New York, USA.
Curiously, not responding at all to pharmacological therapy may sometimes be better for a patient than a partial response, since lack of response forces a change in treatment.
With a partial response, both we and the patient may settle for second-best: a compromise outcome that leaves quality of life and functioning impaired. Perhaps the patient does not complain so much. They may be greatly improved on the standard assessments we apply. Symptoms are not as intense. But if we talk to them with time and attention we can see they are still not satisfied.
They are not as engaged with life as they used to be, and lack motivation and interest. They cannot plan long-term or make decisions. It is like walking through water, or driving a car with the brakes on. Perhaps they have other difficulties, such as anxiety. Though not a core symptom, anxiety is prevalent in depression and can be disabling since it is a great barrier to action and cause of insomnia.
This is surviving, not living. We have treatments that permit the next step. Yet we are perhaps reluctant to change the treatment for fear that what has been gained may be lost. The key, in my opinion, is to augment therapy rather than switch it again.
At this stage, there are several options. Prof Fagiolini stated that thyroid hormones are often not very effective and have side effects, with the risk of atrial fibrillation and osteoporosis. Lithium is a possibility but again there are side effects such as thyroid dysfunction, tremor and nausea. Another option is to add an antipsychotic. A depressed patient may not like the idea because they don’t have psychosis. But this is just a question of nomenclature, not efficacy.
We know that newer antipsychotics, which work on many different receptors and not just dopamine, can also be good as adjunctive treatment to antidepressants. Mechanism of action can be explained to the patient. Each of these agents has different side effects, and choice needs to be tailored to the circumstances of the individual patient. Some will appreciate a sedating action as a side effect, but others not. It is about striking the right balance.
An interview with Andrea Fagiolini, Associate Professor of Psychiatry at the University of Siena School of Medicine, Italy
