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How do we find the right treatments for our patients with schizophrenia at every step of their journey?
In The Split Mind: Schizophrenia from an Insider’s Point of View, author Kevin Alan Lee asserts that the health care system fails when doctors are unable to treat an illness that is treatable. In psychiatry, this failure was an all-too-common occurrence for decades. We are fortunate that there are now more treatment options than ever before for serious mental illnesses, and that many diseases once deemed untreatable can now be managed.
Schizophrenia is a good example of a condition for which there are many available treatments. Different individuals respond better to different treatments, and a treatment that is right for an individual today might not be the best fit for them in a year or a decade. The challenge—or opportunity—we face today involves working with individuals who are living with mental illness and their loved ones to find the right treatment at every step along their disease and life journey.
Understanding Schizophrenia and Treatment
A complex and difficult-to-treat brain disorder, schizophrenia affects about 1% of the US population.1 Typically, symptom onset occurs in young adulthood and can include hallucinations, delusions, disorganized thinking, and behavior associated with psychosis. If left untreated, schizophrenia can have a distressing impact on a person, as well as their family and friends.2
Most people living with schizophrenia require long-term pharmacological treatment, along with psychosocial therapy, to help manage their disease. Since schizophrenia is a chronic condition, long-term disease management should be tailored to the needs and preferences of the patient to best ensure consistent symptom control.2 Disease relapse is a significant challenge in the treatment of schizophrenia, so, as a physician, one of my top concerns is if my patients will continue to take their medication as prescribed.3 This is why I discuss with each patient their overall treatment goals and then the pros and cons of different antipsychotic treatment options available to them. I include in this discussion the 2 main categories of medication delivery: oral and long-acting injectable, which are briefly outlined below.
Oral antipsychotic drugs (OAPs) are widely prescribed to treat many psychiatric conditions in addition to schizophrenia, including bipolar disorder and autism, and as augmentation for major depressive disorder.4
OAPs offer people easy-to-use daily medications to reduce symptoms of mental illness.5,6 However, these medications may cause side effects, including neurological events such as involuntary muscle contractions or, more rarely, tardive dyskinesia. In many cases, these side effects can be managed successfully and will go away after a short period of time.
Atypical OAPs are newer treatment options developed with the goal of delivering effective symptom control with fewer side effects.6 Even so, these medications have come under some scrutiny because they may cause side effects, including weight gain and metabolic adverse effects.4
OAPs are the best choice for many individuals. For instance, I had a patient with exacerbated psychosis and schizophrenia. After discussing available treatments, his fear of needles, and his previous medical history, he decided an OAP was right for him. We found a medication that worked well to control his symptoms with less severe side effects than other treatments he previously tried. He is now a part-time employee, living and volunteering in a group home as a peer advocate who engages others about how manageable conditions like schizophrenia can be.
Different treatments address diverse clinical and lifestyle needs for those living with schizophrenia. Research findings have shown nonadherence rates of up to 68.8% among individuals receiving OAPs for the management of schizophrenia.7 Long-acting injectables (LAIs) were designed to support continuity of treatment.
Formulated to maintain stable therapeutic blood levels during the period between injections (most often every 4 to 8 weeks), LAIs reduce the need to for individuals to remember to—or be reminded to—take their medication and can enhance autonomy.8 LAIs can also reduce the risk of unintentional or deliberate overdoses by offering clinicians transparency if patients fail to take their medication.9
Studies have shown that LAIs may lower risk of hospitalization or relapse compared to OAPs.10 However, LAIs do come with considerations, including less flexibility in dosing adjustment and side effects, including pain at the injection site, or leakage of the drug into the subcutaneous tissue that causes irritation and lesions.6
LAIs are an important treatment option for some individuals. One patient of mine, a 20-year-old straight-A college student, came to us for a manic episode presenting with psychosis. While in the hospital, she received an injection that gave her relief from the distress, paranoia, agitation, and fear that she was feeling. The autonomy that an LAI offered represented the right ongoing treatment choice for her. She has graduated college, become an advocate for others with serious mental illness, and is founding a startup company.
It is important to note that, in the past, LAIs were sometimes used in inpatient settings to ensure medication compliance. This has led some people to view injections as punitive. Some clinicians believe that patients will react negatively to the idea of an injection, which may lead them to avoid discussing this option. However, to prescribe medications that best align with patients’ goals, we must overcome this and work together with our patients to explore all possible treatment options—both their benefits and their drawbacks.
Because of innovations in psychiatry, there are now fewer “untreatable” diseases. Symptom control is critical to well-being in mental illness, but we cannot forget patients’ goals or needs. It is important for physicians and patients to establish genuine rapport, carefully weigh treatment options, and develop a plan that ensures the patient has the right treatment at the right time in their journey.
Dr Amin is chief medical officer of Athena Care located in the Nashville area, where he often works with patients with schizophrenia.
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10. Kishimoto T, Hagi K, Kurokawa S, et al. Long-acting injectable versus oral antipsychotics for the maintenance treatment of schizophrenia: a systematic review and comparative meta-analysis of randomised, cohort, and pre-post studies. Lancet Psychiatry. 2021;8(5):387-404.