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 (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.
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