“Customized Schizophrenia Treatment”: Benefits of Therapeutic Innovations in Inpatient and Outpatient Care Thanks to Gentler Antipsychotics

Recovery as a Goal of Schizophrenia Treatment

The prevalence of schizophrenia in the adult population was 0.45% according to 2021 data. Therapy includes pharmacological procedures to address symptom control (but also bring side effects) and non-pharmacological methods such as education, psychotherapy, and cooperation with field teams or community services.

Currently, alongside managing acute psychotic symptoms, there is a strong emphasis on achieving “recovery” – changes in one's attitudes, values, feelings, goals, and skills to live satisfactorily within the limits caused by the illness. It's a subjective process informed by patient testimonies and measurements of life quality. Recovery is demonstrated by achieving goals in four domains: social situation, employment and finances, physical health, and housing and home. Patients with schizophrenia often set more modest goals (e.g., having a relationship with the family, some friends, any partner, returning to work/school, or finding a job) compared to patients with depression (who often want to improve family relations, build friendships, see old friends at work, improve their job situation, and enhance their intellectual and creative abilities).

Don't Forget Depressive Comorbidities

MUDr. Jana Hořínková from the Psychiatric Clinic of LF MU and FN Brno shared two case studies with the audience, demonstrating the use of lurasidone for effective treatment of psychotic and depressive symptoms, rationalizing antipsychotic therapy while maintaining good efficacy, and even reducing body weight.

The first case dealt with treating psychotic and depressive symptoms in a 41-year-old patient. Depressive symptoms immediately disrupt his participation in life. It's crucial to remember that patients with schizophrenia can also suffer from depression, which needs to be addressed and treated. Managing these symptoms, including depressive ones, increases the patient's functionality, leading them gradually towards recovery.

The second case, a 40-year-old patient, discussed the rationalization of hypertrophied pharmacotherapy and what can be managed in outpatient care without hospitalizing the patient. Psychiatrists in outpatient settings observe that patient compliance decreases with polypharmacy. They propose reducing hypertrophied medication and simpler therapeutic regimens, such as taking medication in one daily dose. The case study showed that even more complex therapy changes can be done outpatient. Detailed patient education, possibly involving the family, and mutual trust and cooperation are crucial (e.g., the patient can call if something worsens, knowing the doctor will address it with them).

The presenter emphasized that the goal of schizophrenia therapy is remission or at least a significant reduction of symptoms with minimal side effects and maintaining the highest possible quality of life. According to her, treatment innovations should not be overlooked, as they can lead to better outcomes.

Compliance in Inpatient and Outpatient Care and How to Strengthen It

MUDr. Adam Fiala from the psychiatric outpatient clinic in Brno noted at the outset that his former work experience at the clinic in Brno-Bohunice provides a good comparison. In the hospital, the focus is on treating the acute phase—alleviating restlessness, addressing positive symptoms, improving the patient's condition, and having them adapt well to routine, functioning well within the ward. However, in outpatient care, the same high-potency antipsychotics don't work as effectively. Patients continue to gain weight, the medication acts sedatively, relatives notice and point it out, and the patient starts perceiving the medication negatively, eventually stopping it. Even though psychiatrists think they can identify and pinpoint such patients, they often find out about medication discontinuation perhaps half a year later, leading to hospitalization. “They often had significant side effects we might not have noticed,” the presenter added.

In two case studies, one of a man and one of a woman, he demonstrated the benefits of switching a patient on antipsychotics with adverse effects to lurasidone. In the first case, the main problem for the patient was the sedative effect of olanzapine; after switching, he was less tired during the day, and his sleep shortened. In the second case, switching to lurasidone helped a patient who had gained significant weight on previous antipsychotic medication. 

Don't Fear New Treatments for Schizophrenia

Experience shows that antipsychotics are only as good as patients' willingness to take them. The presenter noted that in presented cases, patients were willing, and many others would have already quit the medication. He emphasized the need to remember that besides older high-potency antipsychotics with adverse effects, there are new ones, and not to be afraid of using them before patients lose the will to take anything. “Let's not fear them because we risk much more than just the potential return of some positive symptoms. The person's life just heads in an inappropriate direction,” he urged. He highlighted lurasidone's advantage over other antipsychotics, emphasizing its proven efficacy on positive symptoms, meaning even for resistant patients, the switch wouldn't harm and would help by reducing sedation and weight.

Eva Srbová
editor, proLékaře.cz

Sources:
1. Hořínková J. Cases from the ward. Customized Schizophrenia Treatment, Brno, 9. 2. 2023. 
2. Fiala A. Outpatient practice experiences. Customized Schizophrenia Treatment, Brno, 9. 2. 2023.