What are the patients' needs during acute phase schizophrenia therapy and how to increase their adherence?
Treatment of an acute episode of schizophrenia usually requires hospitalization in a psychiatric ward. Even though hospitalization causes discomfort and represents a burden for many patients, it enables quick and relatively precise diagnosis and timely initiation of adequate treatment and monitoring of its effectiveness. Recommended practices guide how to conduct such diagnostics and therapy. One of the symposiums at the 65th Czech-Slovak Psychopharmacological Conference, which took place in mid-January 2023 in Mariánské Lázně, also focused on the management of care for these patients during the first days of hospitalization and after discharge from acute inpatient care.
Establishing Therapeutic Contact and Patient Preferences in the First Days of Acute Hospitalization
The initial therapeutic consideration involves deciding whether it is a first episode or a relapse of the disease. In case of relapse, we try to uncover its cause, most often it is nonadherence to treatment. A careful pharmacological history focused on effectiveness, side effects, and the patient’s attitudes towards antipsychotic treatment often clarifies the reason for the patient's non-compliance.
Establishing therapeutic contact is crucial for the success of both acute and long-term treatment. Most patients do not have insight into their illness. However, they are often able to identify symptoms such as anxiety, fear, agitation, or insomnia. Promising to address these symptoms may help increase the patient's willingness to cooperate. Anxiety, agitation, and insomnia can be managed in two ways. The first is using an antipsychotic with hypnosedative effects (the advantage is monotherapy, the disadvantage is the persistence of the hypnosedative effect even when it is no longer desirable), or by combining an antipsychotic with another hypnosedative medication (taking into account potential interactions when using multiple medications). Preferences of patients using antipsychotic therapy have been evaluated in clinical studies. The most frequently mentioned aspects included improvement of positive symptoms, reduction of weight gain, decrease of hypnosedative effect of medication, absence of metabolic effects and hyperprolactinemia, or improvement of negative symptoms.
Weight gain reduction was observed after switching patients to lurasidone therapy. Lurasidone has a relatively complex receptor profile, acting as an antagonist at dopamine D2, serotonin 5-HT2A and 5-HT7 receptors, and adrenergic α2c receptors, while also being a partial agonist at serotonin 5-HT1A receptors. In terms of effectiveness in acute schizophrenia treatment, lurasidone was comparable to olanzapine. Patients on olanzapine gained an average of 4.6 kg, compared to only 1.5 kg for those on lurasidone. A study comparing lurasidone with risperidone showed an average weight loss of 3 kg after switching to lurasidone. Additionally, prolactin levels were reduced in both men and women.
Optimal medication, however, cannot always be ideally adjusted during hospitalization. Given the trend towards shorter hospital stays, some side effects may manifest later. Thus, the importance of the subsequent - maintenance phase of treatment is increasing.
Patient Needs and Intervention Possibilities Post Discharge from Acute Inpatient Care
Hospitalization is seen as a significant turning point in the lives of mentally ill patients. Practically overnight, the patient is forced to change their usual functioning. They join a collective, follow a regular schedule of activities, and eat regularly. The staff also monitors their adherence to pharmacotherapy. The subsequent transition to the outpatient phase of treatment, however, is often critical. Stress levels increase, and the risk of losing regularity and acquired habits rises, which can lead to another disease relapse.
The mortality and morbidity of mentally ill patients are relatively high. This phenomenon is mainly due to the increased incidence of cardiovascular risk factors (smoking, limited physical activity, dyslipidemia). In response to this problem, we can observe an evolution in antipsychotic consumption. The long-term use of second-generation and atypical antipsychotics is now increasing, and they have significantly fewer metabolic side effects. However, the impact of antipsychotics on insulin resistance remains significant.
Choosing the right psychopharmacological treatment is thus one of the key elements in preventing secondary complications. From the perspective of non-pharmacological interventions, efforts are made to encourage patients to engage in regular physical activity, maintain a balanced diet, ensure quality sleep, establish social contacts, minimize stress, and reduce smoking. The importance of the maintenance phase of treatment is increasing nowadays, given the effort to reduce the duration of hospital stays in all clinical disciplines.
(kali)
Sources:
1. Ustohal L. Patient Needs and Intervention Possibilities in the First Days of Acute Hospitalization. 65. Czech-Slovak Psychopharmacological Conference, Mariánské Lázně, January 11–15, 2023.
2. Anders M. Patient Needs and Intervention Possibilities Post Discharge from Acute Inpatient Care. 65. Czech-Slovak Psychopharmacological Conference, Mariánské Lázně, January 11–15, 2023.
Did you like this article? Would you like to comment on it? Write to us. We are interested in your opinion. We will not publish it, but we will gladly answer you.