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KEY CONCEPTS

KEY CONCEPTS

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

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

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

  • imageA 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.

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

  • imagePharmacotherapy guidelines should emphasize antipsychotic 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.

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

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

  • imageThorough 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.

  • imagePharmacotherapy 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.

PATIENT CARE PROCESS

Patient Care Process for Schizophrenia

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Collect

  • Patient characteristics (eg, age, race, sex, gender identity, pregnant)

  • 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 84-10)

  • Blood pressure (BP), heart rate (HR), height, weight, and body mass index (BMI) (See Table 84-11)

  • Labs: Hemoglobin A1c (HgA1c), Lipids, other tests if indicated (See Table 84-11)

Assess

  • Patient’s concerns and attitudes toward treatment, medication adherence (See Table 84-5)

  • 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 84-2)

  • Medication side effects (See Tables 84-7 and 84-11)

  • Appropriateness and effectiveness of current psychotropic regimen

Plan*

  • Actively engage patient in care plan

  • Drug therapy regimen, specify the continuation and discontinuation of existing therapies (See Figure 84-1 and Tables 84-3, 84-4, and 84-6)

  • Monitoring parameters including efficacy and time frame (See Tables 84-10 and 84-11)

  • Patient education (eg, medication, life style management)

  • Referrals to other providers as appropriate (eg, physician, psychologist, social worker)

Implement*

  • Provide patient education regarding all elements of treatment plan

  • Use motivational interviewing and coaching strategies ...

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