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KEY CONCEPTS
Although dysfunction in multiple neurotransmitters is involved in schizophrenia, the etiology is likely mediated by multiple subcellular processes that are influenced by different genetic polymorphisms and developmental environment exposures.
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 use disorders and general medical disorders.
Given that it is challenging to differentiate among antipsychotics based on efficacy, adverse medication effect profiles become important in choosing an antipsychotic for an individual patient.
Pharmacotherapy guidelines should emphasize antipsychotic monotherapies that optimize benefit-to-risk ratios before progressing to medications with greater adverse 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 most patients with schizophrenia 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.
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Patient Care Process for Schizophrenia
Collect
Patient characteristics (eg, age, race, sex, gender identity, pregnancy status)
Patient history (past mental and medical, medication adherence, family, social—diet, alcohol and substance use, tobacco use)
Mental status exam
Medications (current and past)
Objective data
Brief Positive and Negative Symptom Scales (see Table 91-11)
BP, HR, height, weight, and body mass index (BMI) (see Table 91-12)
Labs: Complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid function tests, hemoglobin A1c (HgA1c), lipids, other tests if indicated (see Table 91-12)
Assess
Patient’s life goals and goals for treatment
Patient’s concerns and attitudes toward treatment, medication adherence (see Table 91-5)
Symptom severity and the extent that treatment goals have been met
Do any co-occurring disorders (mental, substance use disorder, medical) need to be addressed?
Are patient’s psychosocial needs being met? (see Table 91-2)
Adverse medication effects (see Tables 91-7 and 91-12)
Potential for medication interactions (see Tables 91-9 and 91-10)
Appropriateness and effectiveness of current psychotropic regimen
Plan*
Actively engage patient in care plan
Medication therapy regimen (eg, specify the continuation and discontinuation of existing therapies) (see Fig. 91-1 and Tables 91-3, 91-4, and 91-6)
Monitoring parameters including efficacy and time frame (see Tables 91-11 and 91-12)
Patient education (eg, medication, life style management)
Referrals to ...