Short and Long Term Considerations in the Management of Schizophrenia

SHORT AND LONG TERM AIMS IN SCHIZOPHRENIA

Acute Treatment

There are treatment algorithms for the pharmacological treatment of first-episode psychosis to lessen symptoms, for which there is an international consensus that states that treatment should continue for at least 2 years. However, some patient subsets may require up to 5 years. [Birchwood and Fiorillo 2000]

During this critical period, continuity of care is a key goal of recovery.

Recovery Paradigm

A suitable recovery paradigm doesn’t just include clinical recovery (lessening of symptoms) but also includes personal recovery (changing one’s attitudes, values, feelings, goals, skills and/or roles) and functional recovery (employment, education, housing, relationships, and health). [Slade 2009]

Previous research has suggested that early functional recovery is more predictive than clinical recovery for remission over the long-term. [Alvarez-Jimenez 2012]

A functional recovery strategy involves the establishment of a healthy therapeutic relationship and that each of the following factors is considered or addressed when providing an optimal recovery paradigm:

• Socio-demographic profile – Age, sex, education, employment, accommodation and income
• Clinical presentation – Psychopathology, functioning, disability, and comorbid disorders
• Medication – Polypharmacy, psychotherapy, treatment-emergent side effects
• Functioning – Physical health, cognitive function, and social and family relationships

WHAT IS IMPORTANT FOR THE PATIENT?

Ongoing residual symptoms, unemployment and financial problems, homelessness, poor physical health, smoking and substance use are some of the significant challenges that have been identified as key risk factors to relapse.

Updated data from the ‘Survey of High Impact Psychosis’ (SHIP) study supports these findings by showing that money, social engagement, and employment are considered by patients to be the most important challenges. [Morgan et al. 2016]

Interestingly, these challenges are not health-related needs but instead financial and social; therefore, employment can play a key role as it provides both social engagement and an income. Further points raised by the SHIP analysis show that [Morgan et al. 2016]:

• Financial problems and unemployment – Up to 85% of patients report that government benefits were their main income source, with only 37.5% of patients being employed in the previous 12 months.
• Loneliness and social isolation – Up to 63.2% of patients were reported to have deficits in social skills with self-reported rates of loneliness ranging from 74.7% (patients with delusional disorders) to 93.8% (depressive psychosis).
• Poor physical health – Compared to the general population, life expectancy is reduced by 18.7 years for men and 16.3 years for women.
• Uncontrolled symptoms – Analysis of patients with schizophrenia reveal that the 12-month prevalence of hallucinations and delusions was 55.8% and 60.9%, respectively, while anxiety and depression were 59.8% and 54.5%, respectively.
• Suitable housing – Although 52.6% of patients had stable/suitable housing, 24.7% had changed housing in the previous 12 months while 22.7% were on a public housing waiting list.

BARRIERS TO SHORT TERM RECOVERY

One of the main barriers to recovery is the high rate of metabolic and cardiovascular diseases, which is a leading cause of premature death and is significantly more prevalent than in the general population. [Mitchell et al. 2013]

Although monitoring cardiometabolic health is straightforward (waist circumference and BMI), it needs to be regular and systematic and requires an early and substantial lifestyle intervention to prevent weight gain. [Curtis et al. 2015]

Factors contributing to poor cardiovascular health in schizophrenia:

• Poor lifestyle – High rates of smoking, obesity, lack of physical activity, and poor nutrition are lifestyle factors that are known to increase the risk of cardiovascular disease.
• Antipsychotics – Weight gain of 3.2 kg in the short term and 5.3 kg in the long term occurs with most antipsychotics. [Tek et al. 2016]
• Family history – A family history of diabetes, hypertension, and hypercholesterolaemia are significantly associated with T2DM status in patients with psychosis.

Substance abuse (e.g., cannabis, stimulants, and alcohol) is a common co-morbid health problem (63.2% of men and 41.7% of women) and another major complication for recovery.

In some cases of substance abuse, dependence can significantly worsen disease outcomes, i.e., drug-precipitated psychosis and the development of a chronic and relapsing form of psychosis. [Moore et al. 2012]

LONG TERM FUNCTIONAL RECOVERY

A multifaceted and holistic approach to functional recovery will require services that extend beyond the delivery of just good clinical practice.

Functional recovery for patients with schizophrenia should begin as soon as they are at risk of a first episode (prodromal) and included in any treatment strategy throughout the critical period. [Galletly et al. 2016]

Functional recovery is strongly correlated with real-world social outcomes and cognitive performance:

• Social functioning – A lack of social skills is a major deficit in most patients with schizophrenia, which can reduce patient autonomy and result in social isolation. [Kopelowicz et al. 2006] Social skills training not only improves social functioning but can also improve negative symptoms [Almerie et al. 2015]. However, the literature presents contradictory results, and it may be that other factors (e.g. attention deficits) can limit its effectiveness.

• Cognitive functioning – 80% of patients with schizophrenia display signs of cognitive impairment, which can be defined using a neurocognitive assessment. [Saperstein and Kurtz 2013] Cognitive remediation is a behavioural training-based intervention, which can be used to improve cognitive processes such as attention, memory, executive function, and social cognition. [Wykes et al. 2011]

The Open Dialogue (OD) approach has generated considerable interest. OD was developed during the 1980s in Western Lapland, Finland. Dialogism is defined as a focus on creating dialogue, where a new understanding is constructed with the team while promoting a sense of agency and change for the service user and his or her family. It is an integrative approach that embodies systemic family therapy and incorporates some psychodynamic principles. [Freeman et al., 2018]

In a nonrandomized, 2‐year follow up of first‐episode schizophrenia, hospitalization decreased to approximately 19 days; neuroleptic medication was needed in 35% of cases; 82% had no, or only mild psychotic symptoms remaining; and only 23% were on disability allowance. [Seikkula & Olson, 2004]

While studies have shown promise a recent review of the evidence stated:

Variation in models of OD, heterogeneity of outcome measures, and lack of consistency in implementation strategies mean that although initial findings have been interpreted as promising, no strong conclusions can be drawn about efficacy. Currently, the evidence in support of OD is of low quality, and randomized controlled trials are required to draw further conclusions. [Freeman et al., 2018]

During long-term maintenance, physical health monitoring is especially important in this patient population, which is mainly due to medication-induced weight gain, the onset of diabetes, increased levels of plasma lipids, and abnormal findings on ECGs.

Also, antipsychotics are commonly implicated in increased prolactin levels, movement disorders, and sexual dysfunction.

It is therefore advisable to only continue with antipsychotic therapy assuming the benefits outweigh the side effects.

The systematic monitoring and treatment of side effects is an important part of any functional recovery and if a clinician-defined threshold is reached then an alternative approach—to reduce, cease, or perform a slow crossover titration—may be necessary. [Takeuchi et al. 2017]

CONCLUSION

The clinical management of schizophrenia requires a long-term holistic strategy that goes beyond successful pharmacotherapy to improve quality of life determinants such as homelessness, unemployment, financial constraints, lack of education, and poor social skills.

To address these physicians, counsellors, psychiatrists, and caseworkers should address financial management, independent living, social relationships, regular exercise for antipsychotic-induced weight gain, and co-morbid disorders.

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