Optimizing Management of Schizophrenia with Long-acting Injectables - Episode 2

Diagnosis of Schizophrenia Relapse

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Sanjai Rao, MD, DFAPA, and Kimberly Garcia, DNP, CRNP, discuss how practitioners diagnose a schizophrenia relapse, and how to discuss relapse with patients.

Sanjai Rao, MD, DFAPA: I’m really curious to know: when you’re seeing patients like this, how do you talk to them about relapse? What do you say to them?

Kimberly Garcia, DNP, CRNP: I try to take a realistic approach, especially once we have a nice rapport. I look back at my career 10 years ago, in a very optimistic phase of my career. I’d say to my patients, “Do you take your medications?” Of course they would say to me, “Yes, of course I take my medications.” We know that adherence is far more problematic. Once I have a rapport with my patients, I’ll ask them questions such as, “In the last 7 days, how many days do you think you took your medications exactly as prescribed?” It’s amazing the answers I get. You usually have very solid and proud 3 to 4 days per week with strict adherence, meaning a good portion of that time is spent without consistent use of the medications.

Typically, as far as educating them about relapse prevention, I’ll let them know that relapse is almost inevitable. It’s not a matter of if; it’s often a matter of when. I’ll also talk about the fact that with each recurrence that they have, each symptom relapse, they lose a little functionality, which they may not regain, and about the cumulative impact that has on quality of life.

Sanjai Rao, MD, DFAPA: That’s such a key point, that relapses aren’t created equal. The further down the line you go, the harder it becomes to treat. You lose function, and it’s harder to get better. It takes longer to get better. It often takes more medication to get better. I say this to them a lot too: “If we do this better in the beginning, we can avoid going down this path where you end up needing more meds and lots of different meds. The further down we get and the more times you relapse, the more aggressively we’ll have to medicate you to get you well. Let’s try and avoid that. Let’s try to head that off at the pass by doing this now.” It’s great that you talk to them about relapse and that you’re up front with them. My experience has been that it’s something clinicians tend to avoid. We want to say to them, “If you take your meds, then you’re going to be fine,” but that’s not reality.

Kimberly Garcia, DNP, CRNP: Right.

Sanjai Rao, MD, DFAPA: Do you find that clinicians sometimes don’t talk about relapse?

Kimberly Garcia, DNP, CRNP: Absolutely. It’s an important piece, and I try to reinforce that too with students. We teach them about the kindling effect of schizophrenia. It’s an ethical responsibility that we have to our patients to advise them of the likely course prognosis of their disease process and ways that we can have an impact for them.

Sanjai Rao, MD, DFAPA: Absolutely. The other thing I liked was the way you ask patients about whether they’re taking their meds. When we think about how we assess this, it’s often the way you said at the beginning, right? We say, “Do you take your medications?” We’re giving them this binary choice, right? They can say yes or no. If they say no, then they automatically know they’re going to be disappointing us. If there’s any yes at all, even if they take just a few meds, they might say yes but they’re taking it 2 or 3 days a week or something like that. I like your way of doing it: you ask how many days. Have you been doing that all along? Is that something you came up with after doing this for a while?

Kimberly Garcia, DNP, CRNP: It’s taken experience and being more realistic. Professional comfort comes from years of working with individuals who have schizophrenia to realize that if we’re not allowing them the opportunity to admit to issues with medications or whether they’re taking them, then they won’t go there. If we open the door, they’ll oftentimes walk through.

Sanjai Rao, MD, DFAPA: I agree. It’s interesting, there’s some literature on how effective we are at figuring out whether patients are taking medications and even how effective patients are at accurately reporting it. Asked in a simplistic way, we’re terrible and they’re terrible, right?

Kimberly Garcia, DNP, CRNP: Exactly.

Sanjai Rao, MD, DFAPA: Patients typically misremember or misreport how much they take their medications if you ask them yes or no. We typically overestimate patient adherence, when we’re asked, “Do you think patients take their meds?”It’s easy to figure out. You can compare it with things like MEMS [Medication Event Monitoring System] cap and plasma levels, and you can see we’re way off compared with the objective measures of what’s happening.

Kimberly Garcia, DNP, CRNP: Absolutely. Even now, we can search in the electronic record. We’re able to look at the refill dates, like the dates that their pharmacies dispense medications. That has been very telling. When you see that 30-day supply of medications is lasting for 90 or 120 days, and they’ll say, “This medication doesn’t seem like it’s working for me.”

Transcript edited for clarity.