Schizophrenia: Management Strategies

Although only 1 in 100 people develops schizophrenia, this chronic illness disproportionately devastates a patient’s life, causing multiple mental and social problems. Schizophrenia is the fourth leading cause of disability in adults.¹ Schizophrenia affects men and women equally, generally developing as patients enter adulthood.² Its hallmark symptoms are fairly well known to health care practitioners (Table 1^2,3) and even the lay public, mainly because individuals with schizophrenia are common (and often maligned) subjects on television and in the movies. The risk factors that predispose patients to schizophrenia are family history and environmental and developmental dynamics. Researchers know that hyperdopaminergic activity in the brain’s mesolimbic pathway is involved in schizophrenia, and antipsychotics that antagonize postsynaptic dopamine receptors can alleviate (but rarely eliminate) symptoms.³

Disease Management

Health care systems have employed disease management strategies for a number of conditions (eg, asthma, diabetes, other chronic illnesses) and improved therapeutic outcomes. Developing disease management strategies for schizophrenia is possible, as this disease has components similar to those of other chronic illnesses that respond to planned intervention (Online Table 2^4-10).^3,4,8

Table 2: Disease Management: Targeting Schizophrenia

Disease Management Component

Examples of Applications in Schizophrenia

• Patient population can be identified and stratified as high, medium, and low concerning certain criteria (eg, risk of complications, avoidable adverse events).

• Diagnosis criteria are clear, and schizophrenics can be stratified by risk for adverse drug reactions, hospitalization, and suicide.
• Biomarkers to stratify patients are under development; patients and their caregivers would welcome such tools.

• Evidence-based practice guidelines are available to physicians and other providers and address patients’ treatment adherence and necessary support measures.

• The American Psychiatric Association published its Practice Guideline for the Treatment of Patients with Schizophrenia in 2004, with a Guideline Watch (a type of update) in 2009.
• The Schizophrenia Patient Outcomes Research Team (revised 2009) developed evidence-based practices for schizophrenia based primarily on empirical data. Recommendations include 16 drug treatments.
• The Substance Abuse and Mental Health Services Administration developed the Medication Management Approaches in Psychiatry (MedMAP), with a specific treatment module that addresses schizophrenia based on The Texas Medication Algorithm Project (TMAP).

• Services that enhance the patient’s self-management and treatment plan adherence are known.

• The Program for Assertive Community Treatment (PACT) is 1 of 6 practices endorsed by the “Evidence-Based Practice Project” sponsored by numerous organizations. PACT promotes around-the-clock access to care, small caseloads, ongoing and continuous services, assertive outreach, and treatment and rehabilitation in the patient’s natural environment.
• TMAP focuses on increasing drug therapy’s effectiveness and improving clinical decision-making and practice.

• Routine reporting and feedback are possible.

• Documentation is a routine practice. A MedMAP study found that electronic mental health medical records were 40% more complete and 20% faster to retrieve.

• Providers and patients can communicate and collaborate routinely.

• Behavioral Health Clinical Pharmacists ensure safe, appropriate psychotropic use via direct patient care activities and population management strategies in conjunction with mental health teams.

• Process and outcomes measures are available.

• PACT is associated with improved patient functioning and quality of life, sustained employment, and a 40% reduction in hospitalization in patients with severe chronic schizophrenia.
• Use of TMAP protocols in 547 patients with chronic mental illness at 14 clinics compared with a control group showed that patients, whose physicians used the TMAP algorithms, were twice as likely to have significant provider-documented improvement and 3 times more likely to have self-reported improvement.

^{Adapted from references 4-10.}

Disease management strategies are effective, but barriers include clinician resistance. Clinicians who understand the intent and value of disease management strategies tend to accept and use them. Collaboration with patients is also considered galvanizing. Inadequate technology, poor work flow, patient barriers, regulatory barriers, lack of flexibility, and dying enthusiasm for the program can slow or stop implementation of disease management strategies. Leadership must visibly and financially commit to sustain these programs.¹¹

The Pharmacist’s Role

Pharmacists on mental health teams need to watch clinical research closely. History shows us that, sometimes, research reverses some strategies. For example, after their introduction, schizophrenia guidelines recommended atypical antipsychotics as first-line treatment. However, as clinical evidence has accrued, research has shown that typical antipsychotics’ efficacy is comparable for positive symptoms. Newer guidelines often recommend risperidone (because of its low cost) and intermediate—potency, typical antipsychotics, such as perphenazine and molindone.^12,13

Antipsychotics are most often chosen based on the adverse effect profile (Online Table 3^9,13). In addition, patient adherence is heavily dependent on good support. Sometimes, changing drug formulations can improve adherence. Antipsychotics are available as shortand long-acting injectables, oral solutions, and orally disintegrating tablets.²

Antipsychotic Type

Adverse Effects

Typical antipsychotics

• Increased risk for extrapyramidal adverse effects (AEs): Early-onset dyskinesias (dystonias, akathisia) Parkinsonian symptoms (bradykinesia, pill rolling tremor, shuffling gait)
• Late-onset dyskinesias, often irreversible: Tardive dyskinesia and dystonia Requires dose reduction, treatment with an anticholinergic or a benzodiazepine, or antipsychotic discontinuation
• Elevated prolactin levels, sexual dysfunction, neurolopetic malignant syndrome, and QTc prolongation

Atypical antipsychotics

• Metabolic Syndrome Weight gain, elevated low-density lipoprotein and triglyceride levels, type 2 diabetes, hypertension, and increased waist circumference Lower risk with aripiprazole, ziprasidone, and lurasidone
• Sedation, orthostatic hypotension, QTc prolongation, and anticholinergic AEs
• Clozapine can cause agranulocytosis and requires routine white blood cell and absolute neutrophil count monitoring

^{Adapted from references 9 and 13.}

Individuals with schizophrenia often develop comorbid medical and psychiatric illnesses. The potential for drug-induced disorders and drug—drug interactions is high. This, too, is a monitoring issue for pharmacists.

End Note

In addition to understanding medication concerns in schizophrenia, pharmacists must appreciate the need for team-based care of patients with schizophrenia. These patients and their families face often insurmountable challenges. They need education, supportive employment, cognitive-behavioral therapy, and social skills training. Often, weight management and substance abuse services are also necessary. Disease management coordinates all of these needs.¹³

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy.

• Top 10 causes of disability in the US. protectyourincome.com website. protectyourincome.com/the-10-leading-causes-of-disability. Accessed November 1, 2015.
• Muzyk A. Update on the treatment of schizophrenia. Pharmacy Choice website. pharmacychoice.com/education/diseases/schizophrenia.cfm?disease=schizophrenia. Accessed November 1, 2015.
• National Pharmaceutical Council, Inc. Disease management for schizophrenia. February 2004. npcnow.org/system/files/research/download/DM%20for%20Schizophrenia.pdf. Accessed November 1, 2015.
• Kreyenbuhl J, Buchanan RW, Dickerson FB, Dixon LB. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr Bull. 2010;36(1):94-103. doi: 10.1093/schbul/sbp130.
• Hill RR, Herner SJ, Delate T, Lyman AE Jr. Ambulatory clinical pharmacy specialty services: the Kaiser Permanente Colorado experience. J Manag Care Spec Pharm. 2014;20(3):245-253.
• Tsai J, Bond G. A comparison of electronic records to paper records in mental health centers. Int J Qual Health Care. 2008;20(2):136-143.
• Rose D, Papoulias C, MacCabe J, Walke J. Service users’ and carers’ views on research towards stratified medicine in psychiatry: a qualitative study. BMC Res Notes. 2015;8:489. doi: 10.1186/s13104-015-1496-y.
• Bartholomew T, Zechner M. The relationship of illness management and recovery to state hospital readmission. J Nerv Ment Dis. 2014;202(9):647-650. doi: 10.1097/NMD.0000000000000177.
• Moore TA, Buchanan RW, Buckley PF, et al. The Texas Medication Algorithm Project antipsychotic algorithm for schizophrenia: 2006 update. J Clin Psychiatry. 2007;68(11):1751-1762.
• King County (WA) Mental Health, Chemical Abuse and Dependency Services. Program for Assertive Community Treatment (PACT). King County website. kingcounty.gov/healthservices/MentalHealth/Services/ACT/PACT.aspx. Accessed November 1, 2015.
• El-Mallakh P, Howard PB, Bond GR, Roque AP. Challenges of implementing a medication management evidence-based practice in a community mental health setting: results of a qualitative study. Issues Ment Health Nurs. 2014;35(7):517-525. doi: 10.3109/01612840.2014.888601.
• Rosenheck RA, Leslie DL, Busch S, Rofman ES, Sernyak M. Rethinking antipsychotic formulary policy. Schizophr Bull. 2008;34(2):375-380.
• Dixon L, Perkins D, Calmes C. Guideline watch (September 2009): practice guideline for the treatment of patients with schizophrenia. psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia-watch.pdf. Accessed November 1, 2015.