Schizophrenia Follow-up
- Author: Frances R Frankenburg, MD; Chief Editor: Eduardo Dunayevich, MD more...
Further Inpatient Care
- Inpatient hospitalizations are preceded 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 inpatient staff, particularly the psychiatric nurse, is to assess the cause for the hospitalization; monitor response to therapy; and provide education, 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. Some 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
Many have wondered if the prognosis of this illness would be better if treatment could be started as early as possible. The North American Prodrome Longitudinal Study involves a group of 8 research centers that identifies young people at risk. These are people with brief psychotic symptoms or those with a genetic risk for schizophrenia who begin to have a decrease in functioning. The results of this study are mixed. Whether people who meet these criteria should be treated with medications is unclear.[57]
Complications
Alcohol and drug abuse (including nicotine) 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. Drug use and abuse can increase the symptoms of this disorder. For example, cannabis use has been shown to correlate with adverse symptoms in persons with schizophrenia.[58]
Noncompliance or nonadherence 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. Clinicians in the United States tend to use less IM medication than clinicians in Europe. A large trial compared long-acting injectable risperidone to the psychiatrist’s choice of oral antipsychotic agent. The study found, somewhat to the surprise of many, that the injectable risperidone was not superior to oral medication and was associated with more side effects.[59]
Adherence is usually overestimated by both patient and physician. Nonadherence can be partial or complete, but even partial adherence is associated with relapse.[60] In the past, nonadherence was thought to be due at least in part to the side effects of the conventional antipsychotic agents, such as akathisia. Nonadherence remains a major clinical problem, even with second-generation antipsychotic agents.
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.[61] A recent meta-analysis suggests that antidepressants added to antipsychotics might help treat the negative symptoms of chronic schizoprenia, which can be difficult to distinguish from depression.[62]
A few 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.[62] Most patients are not violent and are usually afraid of others rather than threatening to others. However, the rate of violence in patients with schizophrenia who do not abuse substances is higher than in people without schizophrenia.[63]
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.
- Prognosis is better for people living in low-income and middle-income countries.[64]
- Mortality is higher in patients with schizophrenia than in people without this disease due to many factors, including suicide, lifestyle factors, and, perhaps, poorer medical care and complications of medications. A study from Britain shows that this "mortality gap" is increasing.[65]
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 family can learn to recognize early signs of a decompensation, such as insomnia or increased irritability, is helpful.
A review of 44 studies showed that education of patients about the nature of their illness and treatment, when added to standard care, led to a reduction of rehospitalization and of symptoms.[66] Education may help with adherence to medication and may help the patient cope with their illness better in other ways.
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.
Counseling with respect to sexuality, pregnancy, and sexually transmitted diseases is important for patients with schizophrenia.
Side effects of antipsychotic medications may affect the physical appearance of people; this, in turn, can affect relationships with others and self esteem.[67]
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
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