Assessing the Standard of Care in Schizophrenia

"Assessing the Standard of Care in Schizophrenia" surveys the current standard of care for schizophrenia and where it falls short.

Dr. Jackson asks the panel to characterize the current standard of care for schizophrenia. Spencer Simon describes his outpatient community practice as relying heavily on long-acting injectables, arguing that without confirmed adherence, drug resistance and progressive gray and white matter changes can follow. Dr. Hicks reframes the standard of care around curiosity, explaining that she gives patients five minutes or less to describe how their life has gone over the prior two to three weeks, yielding far more useful information than a rushed clinical checklist. Dr. Alva builds on this, urging clinicians to present patients a full menu of formulations, oral, transdermal, intramuscular, and subcutaneous, and highlights the emerging muscarinic pathway as a genuine shift away from decades of exclusively postsynaptic D2 receptor blockade.

Dr. Jackson then raises the tension between efficacy and adverse events, noting olanzapine remains highly effective but burdened by side effects, while only about 15% of patients actually use long-acting injectables and most remain on oral agents, even when also on an LAI. He asks how clinicians can address metabolic dysfunction, movement disorders, prolactin elevation, akathisia, and drug-induced parkinsonism without sacrificing efficacy. Dr. Hunter responds that clinicians often leave patients on the same acute-stabilization dose indefinitely without reconsidering whether a lower maintenance dose could reduce side-effect burden. He advocates rational combination therapy, pairing agents to reduce a highly efficacious but poorly tolerated drug's dose while preserving benefit, noting some of the most effective regimens combine first- and second-generation antipsychotics. Dr. Hunter stresses individualizing treatment, since patients weigh side effects differently: some tolerate movement symptoms far better than weight gain, and true precision medicine means matching regimens to each patient's priorities.

In "When to Switch Schizophrenia Treatment," the panel will walk through the clinical decision-making behind changing a patient's treatment plan.