Chapter 87: Schizophrenia

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.

• 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 reaction 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 reaction 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 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.

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 87-11)

• Blood pressure (BP), heart rate (HR), height, weight, and body mass index (BMI) (see Table 87-12)

• Labs: Hemoglobin A1c (HgA1c), lipids, other tests if indicated (see Table 87-12)

Assess

• Patient’s concerns and attitudes toward treatment, medication adherence (see Table 87-5)

• 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 87-2)

• Adverse medication reactions (see Tables 87-7 and 87-12)

• Potential for medication interactions (see Tables 87-9 and 87-10)

• Appropriateness and effectiveness of current psychotropic regimen

Plan*

• Actively engage patient in care plan

• Medication therapy regimen (egspecify the continuation and discontinuation of existing therapies) (see Fig. 87-1 and Tables 87-3, 87-4, and 87-6)

• Monitoring parameters including efficacy and time frame (see Tables 87-11...