In the context of the continuing debate and uncertainty about the utility and cost-effectiveness of antipsychotic drugs, quality of life remains the reference point that should direct clini- cal decisions. Prescribing practices should be guided not exclusively by research data but by each individual's needs, idiosyncratic responses, and susceptibilities to adverse effects. Clinical wisdom suggests that the class of antipsychotic drugs doesn't really matter as long as physicians remain diligent and adhere to good prescribing practices (ie, the use of minimal yet effective dosing, timely titration, monitoring of adverse effects, and assessing of individual tolerability), coupled with appropriate psychoeducation and enlistment of family support.

It is neither essential nor is it often feasible to formally assess quality of life in routine clinical practice. The choice of a drug and the decision whether to continue with the same treatment should be guided by the net impact of a medication, taking into account the magnitude of symptom control, the burden of adverse effects, subjective tolerability, and patients' reports of satisfaction with the treatment. A simplified form of the risk-benefit analysis of various psychotropic drugs is summarized in the Table.

 

      
 TABLE
Clinical appraisal of quality of life during treatment*
   High risks/adverse effects
 Low risks/adverse effects
 
 Maximum benefit  Clozapine  SSRIs and  benzodiazepines
 
 Moderate benefit  Conventional  antipsychotics and  tricyclics  Atypical antipsychotics
 
 Minimal or no benefit  Reserpine  Vitamin B6 for tardive  dyskinesia
 
*Based on net subjective satisfaction. A high risk-benefit ratio (ie, disproportionately greater adverse effects relative to a modest relief of symptoms) is often reflected in poor tolerability, lower adherence rates, and compromised quality of life.

Polypharmacy and quality of life
There has been growing evidence to suggest that comorbidity is the rule rather than the exception among many people affected by schizophrenia. Substance abuse and anxiety disorders, especially obsessive-compulsive disorder, are common examples of psychiatric disorders that often coexist with psychotic symptoms. The quest to achieve relief from comorbid symptoms led to the unintended practice of prescribing multiple, adjunctive psychotropic medications. Benzodiazepines and antidepressants are the concurrent medications most widely used with antipsychotic medications; other common concurrent medications include antiepileptics and lithium. The clinical reality is that patients who are denied the opportunity of optimal pharmacotherapy tend to self-medicate with a range of over-the-counter medications (eg, antihistamines) or illicit drugs (eg, cannabis).

The evidence to help appraise the impact of polypharmacy, especially from a quality-of-life perspective, is still accruing and is inconclusive. While some studies show that planned, carefully monitored, targeted use of adjunctive medications offers additional relief of symptoms and enhances overall functioning and quality of life, there is a nagging concern that lapses in the continuity of care could result in inappropriate and long-term use of multiple medications as well as consequent cumulative adverse effects and impairment.

Psychosocial interventions and quality of life Nonpharmacological approaches are an integral part of enhancing quality of life for persons with schizophrenia. Timely introduction of psychoeducation, compliance therapy, family intervention, stress management, social skills training, and cognitive remediation techniques in suitably selected patients may complement the benefits of drug therapy and greatly enhance a patient's recovery and quality of life.

The new era of PROs
Research on quality of life has helped keep the focus on the subjective aspects of the illness experience and treatment and has identified a wide range of PROs.11 In recent years, the FDA has not only insisted on the collection of PRO data in clinical trials but it has also taken them into con- sideration in the new drug-approval process.

Conclusion
Enhancing quality of life is an evolving theme and a moving target. It is popular yet controversial, desirable yet demanding. Despite the potential difficulties and uncertainties, enhancing the quality of life of individuals with schizophrenia is a worthy goal for clinicians. While the conventional wisdom of do no harm is a reminder of the limitations of drug therapy, the motto care often, cure sometimes, and comfort always distills the scope of enhancing quality of life in health care.

Acknowedgment—in memory of Warren Robertson.
 
Pages: 1  2