Psychiatric Times.
No. 4
Treatment Challenges in Schizophrenia: A Multifaceted Approach to Relapse Prevention
By Shirly Mahgerefteh, Joseph M. Pierre, MD, and Donna A. Wirshing, MD |
April 1, 2006
Maximizing functionality
Psychiatric rehabilitation and interventions focusing on the functional impairments of an illness are vital for optimizing the patient's position in the community.24 The symptoms of schizophrenia, particularly the negative symptoms (social withdrawal, lack of motivation, and anhedonia), will impair a patient's function in the community. These factors can negatively affect a person's everyday life and self-esteem. Barkic and colleagues25 reported significant improvement in cognitive functioning after switching patients from a first-generation antipsychotic to risperidone(Drug information on risperidone) (Risperdal). Their results and other findings supporting the use of a newer antipsychotic over a first-generation antipsychotic for functional outcomes may be a function of the newer drugs' effects on biologic mechanisms affecting cognitive functioning, their decreased risk of extrapyramidal side effects, or the improvements they produce in mood and motivation.26 Pharmacotherapy aimed at symptom control at the lowest possible dosage will enhance patient functionality.
Pharmacotherapy must be augmented by psychosocial interventions. A multi-staged cognitive therapy for psychotic disorders that teaches patients to assess, cope with, understand, selfevaluate, and manage risks associated with their illness may significantly improve positive symptoms.27 Many researchers have reported improvement in adherence, cognitive and social function, and employment when skills training, psychosocial interventions, and supportive services were included as components of treatment.5,28-31 For example, supported employment may compensate for the effects of cognitive impairment on employment.32 Other specific psychotherapeutic interventions directed at improving overall functioning may include cognitivebehavioral therapy, occupational therapy, family therapy, and motivational interviewing.
While domain-specific interventions do produce successful results,33 Zygmunt and associates31 found that overall, programs involving concrete problem solving and principles of motivational interviewing were most effective. Rossotto and coworkers34 found that an outpatient adaptation of a community reentry module for patients with schizophrenia and patients with schizoaffective disorder more than doubled the likelihood of keeping clinical appointments and drastically lowered rehospitalization rates in the 12-month period following completion of the study. The weekly sessions incorporated motivational interviewing, video demonstrations, role playing, problem-solving exercises, and in-class and community assignments to help bridge the gap between inpatient hospitalization and outpatient treatment. Educating patients about their illness and teaching coping skills should be the minimal nonpharmacologic treatment patients receive.
Teaching patients coping skills in
order to better respond to their symptoms,
medication side effects, and
stigmatization may help improve functionality
and quality of life in schizophrenia.
Stigmatization particularly
affects quality of life by serving as a
barrier to employment. Social factors
are a greater influence on employment
than any intrinsic characteristic of
schizophrenia.
Rates of employment among the mentally ill have been dropping since the deinstitutionalization movement.35 This may be a result of a lack of emphasis on employment during rehabilitation or the patient's own fear of losing government disability income. Occupational therapy can improve the quality of time spent by patients with schizophrenia on a daily basis36 and give patients the necessary tools to find and maintain employment.
Conclusion
Although antipsychotic therapy is the
chief component of the management of
schizophrenia, a number of other
elements can be integrated into a comprehensive treatment plan. Clinicians
should be aware of the possibility
of social, cognitive, emotional, and
medical impairments associated with the
illness so that they can be better prepared
to identify and tackle symptoms and
medication side effects. Patients need
to be monitored closely, even while
psychiatric symptoms are in remission
during antipsychotic treatment.
Check-in appointments once per
week just for supportive therapy are
beneficial when patients make the transition
from the hospital to the community.
We recommend tapering visits to
every 2 weeks after 6 months, then
monthly visits thereafter. It is important
to remember that no single treatment
method can fully cater to all the
different aspects of a patient's wellbeing.
Beneficial long-term outcomes
in the community lives of persons with
mental illness may be more effectively
achieved by integrated methods of treatment
applied by a collaborative group
of clinicians.
Ms Mahgerefteh is a research assistant and
healthy lifestyles coach at the Schizophrenia
Research Clinic at the VA Greater Los Angeles
Healthcare System.
Dr Pierre is associate clinical professor of
psychiatry at the University of California, Los
Angeles, David Geffen School of Medicine and
Staff Psychiatrist at the VA Greater Los
Angeles Healthcare System.
Dr Wirshing is associate professor of psychiatry
at the University of California, Los
Angeles, David Geffen School of Medicine and
is co-chief of the schizophrenia inpatient
treatment unit and the schizophrenia research
clinic of the VA Greater Los Angeles
Healthcare System. The authors have no conflicts
of interest to report regarding the subject
matter of this article.
References
1. Leucht S, Barnes TR, Kissling W, et al. Relapse prevention in schizophrenia with new-generation antipsychotics: a systematic review and exploratory meta-analysis of randomized, controlled trials. Am J Psychiatry. 2003;160:1209-1222.
2. Moller HJ, Llorca PM, Sacchetti E, et al. Efficacy and safety of direct transition to risperidone longacting injectable in patients treated with various antipsychotic therapies. Int Clin Psychopharmacol. 2005;20:121-130.
3. Kopelowicz A, Liberman RP. Integrating treatment with rehabilitation for persons with major mental illnesses. Psychiatr Serv. 2003;54:1491-1498.
4. Le Fauve CE, Litten RZ, Randall CL, et al. Pharmacological treatment of alcohol abuse/dependence with psychiatric comorbidity. Alcohol Clin Exp Res. 2004;28:302-312.
5. Shaner A, Eckman T, Roberts LJ, Fuller T. Feasibility of a skills training approach to reduce substance dependence among individuals with schizophrenia. Psychiatric Serv. 2003;54:1287-1289.
6. Drake RE, Mueser KT. Psychosocial approaches to dual diagnosis. Schizophr Bull. 2000;26:105-118.
7. Drake RE, Essock SM, Shaner A, et al. Implementing dual diagnosis services for clients with severe mental illness. Psychiatric Serv. 2001;52:469-476.
8. Pallanti S, Quercioli L, Hollander E. Social anxiety in outpatients with schizophrenia: a relevant cause of disability. Am J Psychiatry. 2004;161:53-58.
9. Braga RJ, Mendlowicz MV, Marrocos RP, Figueira IL. Anxiety disorders in outpatients with schizophrenia: prevalence and impact on the subjective quality of life. J Psychiatr Res. 2005;39:409-414.
10. Wetherell JL, Palmer BW, Thorp SR, et al. Anxiety symptoms and quality of life in middle-aged and older outpatients with schizophrenia and schizoaffective disorder. J Clin Psychiatry. 2003;64:1476-1482.
11. Kingsep P, Nathan P, Castle D. Cognitive behavioural group treatment for social anxiety in schizophrenia. Schizophr Res. 2003;63:121-129.
12. Meltzer HY. Treatment of suicidality in schizophrenia. Ann N Y Acad Sci. 2001;932:44-60.
13. Siris SG. Suicide and schizophrenia. J Psychopharmacol. 2001;15:127-135.
14. Desai RA, Dausey DJ, Rosenheck RA. Mental health service delivery and suicide risk: the role of individual patient and facility factors. Am J Psychiatry. 2005;162:311-318.
15. Bourgeois M, Swendsen J, Young F, et al. Awareness of disorder and suicide risk in the treatment of schizophrenia: results of the international suicide prevention trial. Am J Psychiatry. 2004; 161:1494-1496.
16. Meltzer HY. Suicide in schizophrenia, clozapine, and adoption of evidence-based medicine. J Clin Psychiatry. 2005;66:530-533.
17. Wirshing DA. Schizophrenia and obesity: impact of antipsychotic medications. J Clin Psychiatry. 2004;65:13-26.
18. Wirshing DA, Danovitch I, Erhart SM, et al. Update on atypicals: practical tips to manage common side effects. Curr Psychiatry. 2003;2:49-57.
19. American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the Study of Obesity. Consensus development conference on antipsychotic drugs and obesity and diabetes. J Clin Psychiatry. 2004;65:267-272.
20. Evans S, Newton R, Higgins S. Nutritional intervention to prevent weight gain in patients commenced on olanzapine: a randomized controlled trial. Aust N Z J Psychiatry. 2005;39:479-486.
21. Kalarchian MA, Marcus MD, Levine MD, et al. Behavioral treatment of obesity in patients taking antipsychotic medications. J Clin Psychiatry. 2005;66:1058-1063.
22. Wirshing DA, Smith RA, Erickson ZD, et al. A wellness class for inpatients with psychotic disorders. J Psychiatr Pract. 2006;12:24-29.
23. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with
lifestyle intervention or metformin. N Engl J Med. 2002;346:393-403.
24. Torrey WC, Green RL, Drake RE. Psychiatrists and psychiatric rehabilitation. J Psychiatr Pract. 2005;11:155-160.
25. Barkic J, Filakovic P, Radanovic-Grguric L, et al. The influence of risperidone on cognitive functions in schizophrenia. Coll Anthropol. 2003;27(suppl 1):111-118.
26. Velligan DI, DiCocco M, Bow-Thomas CC, et al. A brief cognitive assessment for use with schizophrenia patients in community clinics. Schizophr Res. 2004;71:273-283.
27. Glynn SM. The challenge of psychiatric rehabilitation in schizophrenia. Curr Psychiatry Rep. 2001;3:401-406.
28. Lehman AF, Buchanan RW, Dickerson FB, et al. Evidence-based treatment for schizophrenia. Psychiatr Clin North Am. 2003;26:939-954.
29. Oka M, Otsuka K, Yokoyama N, et al. An evaluation of a hybrid occupational therapy and supported employment program in Japan for persons with schizophrenia. Am J Occup Ther. 2004;58:466-475.
30. Percudani M, Barbui C, Tansella M. Effect of second-generation antipsychotics on employment
and productivity in individuals with schizophrenia: an economic perspective. Pharmacoeconomics.
2004;22:701-718.
31. Zygmunt A, Olfson M, Boyer CA, Mechanic D. Interventions to improve medication adherence in
schizophrenia. Am J Psychiatry. 2002;159:1653-1664.
32. McGurk SR, Mueser KT. Cognitive functioning, symptoms, and work in supported employment: a review and heuristic model. Schizophr Res. 2004;70:147-173.
33. Bustillo J, Lauriello J, Horan W, Keith S. The psychosocial treatment of schizophrenia: an update. Am J Psychiatry. 2001;158:163-175.
34. Rossotto E, Wirshing DA, Liberman RP. Rehab rounds: enhancing treatment adherence among
persons with schizophrenia by teaching community reintegration skills. Psychiatric Serv. 2004;55:26-27.
35. Marwaha S, Johnson S. Schizophrenia and employment—a review. Soc Psychiatry Psychiatr Epidemiol. 2004;39:337-349.
36. Minato M, Zemke R. Time use of people with schizophrenia living in the community. Occup Ther Int. 2004;11:177-191.
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