eMedicine Specialties > Psychiatry > Adult

Schizophrenia: Follow-up

Author: Frances R Frankenburg, MD, Associate Professor, Department of Psychiatry, Boston University School of Medicine; Chief of Inpatient Psychiatry and Consulting Psychiatrist, Edith Nourse Rogers Memorial Veterans Administration Medical Center; Associate Psychiatrist, McLean Hospital
Contributor Information and Disclosures

Updated: Sep 10, 2009

Follow-up

Further Inpatient Care

• Inpatient hospitalizations are caused by an exacerbation of symptoms, due to medication noncompliance, substance abuse, medication adverse effects or toxicity, medical illness, psychosocial stress, or the waxing and waning of the illness itself.
• Admission to the hospital is stressful for anyone, but for someone with schizophrenia, who can find change difficult and who is suffering an exacerbation of his or her symptoms, it can be particularly frightening. The role of the nurse is important in helping to assess the cause for the hospitalization; monitoring response to therapy; and providing support, reassurance, and encouragement.
• Hospitalizations are usually brief and for the purposes of crisis management or symptom stabilization.
• Some patients are so disorganized because of their symptoms that they are unable to live in the community and live on long term inpatient units. These units are usually found in state hospitals or Veterans Administration hospitals, and are becoming increasingly rare.

Further Outpatient Care

• The bulk of care for patients with schizophrenia occurs in an outpatient setting. This probably is best carried out by a multidisciplinary team. Suggested members of the team include a psychopharmacologist, counselor or therapist, social worker, nurse, vocational counselor, and case manager. Clinical pharmacists and internists can be valuable members.
• Treatment requires an integration of medical, psychological, and psychosocial inputs.
• In the United States, many people with schizophrenia do not live with their families. They do not always have the skills needed for independent living, so a system of alternative housing arrangements has emerged. At their most basic, these systems may consist of boarding houses or single-room occupancy (SRO) hotels with no supervision. Many organizations, often state-supported, provide communal-living settings with 24-hour supervision in halfway houses. Veterans Administration (VA) facilities have developed a sophisticated system of family care homes. Therapeutic halfway houses in which independence and social skills training are encouraged also exist.
• One form of case management known as assertive case treatment is typically used for patients who have had multiple inpatient hospitalizations. The treatment involves active outreach to patients. Case managers usually have a fairly small outpatient load of about 10 patients and are able to go into the community to work with their clients. The managers coordinate and integrate care. The case managers, who may come from various disciplines, identify indications for treatment, make referrals to appropriate services, and promote engagement with interventions. This kind of treatment is very expensive but may be associated with a better clinical and social outcome and decrease in hospitalization.

Deterrence/Prevention

In studies in Norway and North America, researchers have found preliminary evidence that treatment of the prodrome of schizophrenia (the subclinical phase that is a precursor to acute psychosis) may delay onset of psychosis or reduce the severity of the illness.²⁶

Complications

• Alcohol and drug abuse are common. Of patients with schizophrenia, 20-70% have a comorbid substance abuse problem. Comorbid substance abuse, particularly common in younger men, is associated with increased hostility, crime, violence, suicidality, noncompliance with medication, homelessness, poor nutrition, and poverty. Patients who abuse substances may fare better in dual diagnosis treatment programs, in which principles from both mental health and chemical dependency fields can be integrated.
• Noncompliance with medication is difficult to estimate but is common, and it is one of the reasons for the use of intramuscular (IM) preparations of antipsychotic medications. A regular routine of IM medication is preferred by some patients, and it is easier for the clinician to monitor medication adherence when IM medication is used.
• Family and treaters should encourage the person to take their medication, while at the same time respecting his or her autonomy. This is a difficult balance to achieve.
• Many patients with schizophrenia report symptoms of depression. Considerable uncertainty exists as to whether depression is part of schizophrenia, a reaction to the illness, or a complication of treatment. This is a particularly important problem because of the high rate of suicide in patients with schizophrenia. The research evidence for the use of antidepressant agents in schizophrenia is mixed. Further complicating the situation are the findings that antipsychotic agents, even the older conventional agents, may have antidepressant properties.²⁷
• Some patients may be violent, sometimes due to hallucinations or delusions.
  • Because the violence may be unpredictable and bizarre, these events are often highly publicized. An unfortunate consequence is the exacerbation of stigma.
  • Violence may be associated with command hallucinations or substance abuse.²⁸
  • Most patients are not violent and are usually afraid of others rather than threatening to others. The rate of violence in patients with schizophrenia who do not abuse substances is about the same as in people without schizophrenia.

Prognosis

The prognosis of schizophrenia is guarded.

• Patients with schizophrenia have a 10% risk of suicide.
• Full recovery is unusual.
• Symptoms usually follow a waxing and waning course.
  • The patient's pattern of symptoms may change over years.
  • Positive symptoms respond fairly well to antipsychotic medication, but the other symptoms are quite persistent.
• Early onset of illness, family history of schizophrenia, structural brain abnormalities, and prominent cognitive symptoms are associated with poor prognosis.
• This illness is little understood, and the available treatment is unacceptably poor. Research is ongoing into the pathophysiology and treatment of this illness. With earlier intervention with improved agents the goal is complete resolution of all symptoms of this illness and continuation or resumption of a full meaningful life.

Patient Education

• Because of the nature of schizophrenia, the patients may have difficulty understanding the illness. Nevertheless, teaching the patient to understand the importance of medication compliance and abstinence from alcohol and other drugs of abuse is important.
• Working with the patient so that patient and treatment team (and perhaps family members) can learn to recognize early signs of a decompensation, such as insomnia or increased irritability, is helpful.
• Family members should be referred to the National Alliance on Mental Illness (NAMI) (or other appropriate support group if available), which provides many educational opportunities.
• Social skills training is helpful, but the effects are not long-lived. This kind of training, as well as other sorts of problem-solving therapy, may need to be continued on an indefinite basis, similar to the medication.
• Physical illnesses in schizophrenia are common. The importance of a healthy lifestyle and regular health care should be stressed.
• For excellent patient education resources, visit eMedicine's Mental Health and Behavior Center. Also, see eMedicine's patient education article Schizophrenia.
• Other helpful resources are available here:
  • WebMD: Schizophrenia Health Center
  • Mayo Clinic: Schizophrenia
  • National Institute of Mental Health: Schizophrenia
  • Medline Plus: Schizophrenia

Miscellaneous

Medicolegal Pitfalls

• Misdiagnosis is a pitfall. Treatable illnesses, such as Wilson disease, endocrine dysfunction, or infectious illnesses, are particularly important to diagnose.
• Physicians should warn people being treated with conventional antipsychotic agents about the risk of tardive dyskinesia. Regular examinations, using the abnormal involuntary movement scale (AIMS), should be performed to document its presence or absence.
• Do not neglect the medical care of the person with schizophrenia. Obesity, diabetes, cardiovascular disease, and lung diseases are prevalent in schizophrenia, and the person with schizophrenia often does not get adequate medical care.²⁹
• Children, pregnant or breastfeeding women, and elderly patients present special challenges. In all of these cases, use medications with particular caution.

Special Concerns

• Poverty: Because of vocational difficulties, many patients with schizophrenia also have to cope with the burdens of poverty.
• Health insurance: In the United States, patients who do not work may be eligible for governmental programs, such as Medicare and Medicaid. These programs pay the cost of medical care. Unfortunately, once persons begin to work and earn a sufficient salary, they are at risk of losing these benefits. This is particularly awkward because they may be working in a setting with minimal or no health benefits. This situation is complicated and must be monitored closely by professionals with a good understanding of health benefits.
• Informed consent: Consent is a legal term and should be used with respect to specific tasks. A person who is delusional in some but not all areas of life might be adjudicated competent by a court to make medical and financial decisions for him or herself.
• Incarceration: One of the unintended consequences of deinstitutionalization was an increase in the number of chronically mentally ill persons in jails and prisons in the United States.³⁰

I am grateful to Drs Lawrence Herz and Jennifer Kymalainen and also to Stephen Proper for their careful reading of this article; all mistakes are my own.

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