Treating Schizophrenia in the Era of COVID-19 - Episode 4
Bryce Reynolds, MD, and Hannah Phillips-Hall, MSN, PMHNP-BC, discuss the challenges faced when treating patients with schizophrenia and challenges that have presented during the coronavirus pandemic.
Bryce Reynolds, MD: Let’s move away from the cases that we’re talking about. Let’s look at some of the challenges and unmet needs in dealing with patients who have schizophrenia. You know some of the challenges that we’ve already mentioned. There’s the stigma associated with it. There are also cognitive deficits, decrease in insight, decrease in motivation, and social isolation. We also have support systems that may not always see this as a positive thing because of their lack of understanding about it or cultural beliefs, access to services and medications, the office-based visits, transportation difficulties, and financial issues. But 1 of the main issues I constantly see is being able to monitor adherence with a po [oral] medication. We can’t absolutely guarantee that the person is consistently taking their medication. Have you found similar things in your practice? What are your thoughts about treating people with schizophrenia, in terms of the challenges you find?
Hannah Phillips-Hall, MSN, PMHNP-BC: I want to piggyback off this idea of difficulty in truly assessing oral adherence. You’re right. We know if they pick up the medication from the pharmacy. However, they can be going home and using it as fish food or plant fertilizer. We don’t actually know what is happening to those oral medications. A roommate could steal them. Any number of things can occur. That’s a very difficult element in and of itself.
Also, if we do have that family member there, then unfortunately, we’re placing a bit of—I don’t like to use the terms burden or obligation because they love the person they’re caring for. But we can destroy that early relationship dynamic by asking the family member to be their makeshift nurse and trying to monitor if their son, daughter, or even spouse takes the medications. It’s a very difficult thing to incorporate into a relationship.
Bryce Reynolds, MD: Yes. On the other hand, my patients sometimes find it difficult to hear from their parents every single day: “Have you taken your medication? Have you taken your medication?” It makes them feel as if they’re not treated like an adult. This is 1 way you can avoid being asked that question. You can explain to the family that you have a consistent amount of medication. It’s a good point on that 1.
How about the challenges with oral medications during COVID-19 [coronavirus disease 2019]? Do you find differences with that, as opposed to pre-COVID?
Hannah Phillips-Hall, MSN, PMHNP-BC: I’ve been trying to respond to that with my patients who are on oral medications by making sure I’m able to prescribe a 90-day supply if their insurance will accommodate it. However, the concern is if the patient isn’t doing well and is potentially decompensating. Our office hours have been dramatically reduced. The overall question is access to care to receive medication adjustments, not to mention being able to go to the pharmacy to pick up their prescription, etc.
Bryce Reynolds, MD: I’m aware of the adherence issues with po [oral] medications at any time, and COVID-19 certainly has not made it any better. It may have made it worse. But 25% of patients discontinue their medications 7 to 10 days after hospitalization; 35% in 6 weeks; 50% in 6 months. A study that looked at the CATIE study, which examined people 18 months after they started their medications, found that 74% of them were not taking their medications. At that point, 3 of 4 people are not taking their po [oral] medication.
During COVID-19, it’s even harder because they have difficulty accessing the medications. It’s difficult to monitor that. We’re a service. I work on an ACT [assertive community treatment] team, so I’m in the communities. But because of COVID-19, I’m no longer able to go into their homes. I have to see them outside. Monitoring their po [oral] medications, even with pillboxes or bubble packs, is difficult to do when you’re outside their homes. They’re not necessarily wanting to bring medication from inside their home outside. Those things happen.
I also want to point something out about relapse data. One of the studies compared po [oral] medications with injections. On injections, the time to relapse was almost doubled. The time to get into a hospital, go to jail, or decompensate was almost double. What does that give the patient? Is it the ability to work, sustain housing and socialization, and work or go to school? It helps us as providers and it helps our teams be able to work more closely with a patient on maintaining those things. They want to function, but that may be difficult because of their overall illness.
With the COVID-19 risk, you also want to limit that risk of hospitalization and going to the ED [emergency department]. I think about the exposure that they may have in the ED. The cost is so significant. EDs in hospitals have limited resources these days. There are a lot of other patients who require medical care there. If we can keep someone from relapsing back to the hospital, that’s really helpful.
One of the ways we can help monitor the injection part of it and the benefits the patient has is using telehealth. We can certainly utilize that as a means to monitor progress. But typically, telehealth doesn’t tell whether the person is adequately or consistently taking their po [oral] medication. Do you do telehealth in your practice?
Hannah Phillips-Hall, MSN, PMHNP-BC: I didn’t until COVID-19 forced me into this modern age, and I’m loving it. I love that insurance companies are reimbursing for telehealth, which they previously weren’t. That is 1 of the silver linings of COVID-19 that I’m grateful for. I look forward to being able to continue to render telemed services in the future with my patients.
Bryce Reynolds, MD: That sounds really good. I’m curious as to how your prescribing has changed in the past 6 months during COVID-19.
Hannah Phillips-Hall, MSN, PMHNP-BC: You and I had an opportunity to talk a bit before, and I’m going to echo your feeling. My practice of the prescribing hasn’t changed much because, even pre–COVID-19, I was still gung ho on the utilization of long-acting injectables. With COVID-19, it has maybe facilitated a more expedited yes from patients or families. But the only change is the reception or the response to it, especially when we take into consideration how our patients with schizophrenia can decompensate because of increases in stress. That is what COVID-19 is at its core. It is an increase in overall stress societally. I can imagine how that could possibly exacerbate patients’ psychotic symptoms.
Bryce Reynolds, MD: Especially if they’re not taking their po [oral] meds consistently. Thus, there is a need to have long-acting injectables onboard, and there are potential benefits of doing that.