Chapter 67: Schizophrenia

Content Update

December 13, 2017

Aripiprazole Tablets with Sensor (Abilify MyCite) for Treatment of Adults with Schizophrenia: Aripiprazole tablets with sensor (Abilify MyCite) is a drug-device combination product comprised of tablets embedded with an Ingestible Event Marker (IEM) sensor to track drug ingestion. The product is indicated for treatment of schizophrenia, bipolar I disorder, and adjunctive treatment in adults with major depressive disorder. Abilify MyCite has not been established to improve patient adherence, and tracking drug ingestion in "real-time" or during emergencies is not recommended because detection may be delayed or missed.

Content Update

September 16, 2017

Deutetrabenazine and Valbenazine for Treatment of Adults with Tardive Dyskinesia: Deutetrabenazine (Austedo) and valbenazine (Ingrezza) are selective vesicular monoamine transporter 2 inhibitors approved for treatment of tardive dyskinesia. Outcomes of three controlled clinical trials supported superior efficacy and safety compared to placebo in reducing the signs and symptoms associated with tardive dyskinesia in adults. Deutetrabenazine carries a black box warning for increased risk of depression and suicidal thoughts; valbenazine does not have a black box warning, but there is also concern for a potential increased risk of depression and suicidal thoughts with this medication.

KEY CONCEPTS

• Although multiple neurotransmitter dysfunctions are involved in schizophrenia, the etiology is more likely mediated by multiple subcellular processes that are influenced by different genetic polymorphisms.

• The clinical presentation of schizophrenia is characterized by positive symptoms, negative symptoms, and impairment in cognitive functioning.

• Comprehensive care for individuals with schizophrenia must occur in the context of a multidisciplinary mental healthcare environment that offers comprehensive psychosocial services in addition to psychotropic medication management.

• A thorough patient evaluation (eg, history, mental status examination, physical examination, psychiatric diagnostic interview, and laboratory analysis) should occur to establish a diagnosis of schizophrenia and to identify potential co-occurring disorders, including substance abuse and general medical disorders.

• Given that it is challenging to differentiate among antipsychotics based on efficacy, side effect profiles become important in choosing an antipsychotic for an individual patient.

• Pharmacotherapy guidelines should emphasize antipsychotics monotherapies that optimize efficacy-to-side effect ratios before progressing to medications with greater side effect risks. Combination regimens should only be used in the most treatment-resistant patients.

• Adequate time on a given medication at a therapeutic dose is the most important variable in predicting medication response.

• Long-term maintenance antipsychotic treatment is necessary for the vast majority of patients with schizophrenia in order to prevent relapse.

• Thorough patient and family psychoeducation should be implemented, utilizing motivational interviewing methods that focus on patient-driven outcomes in an effort to allow patients to achieve life goals.

• Pharmacotherapy decisions should be guided by systematic monitoring of patient symptoms, preferably with the use of brief symptom rating scales and systematic assessment of potential adverse effects.