Divergent Perspectives Threaten Schizophrenia Treatment

Although schizophrenia affects roughly 1 percent of the population, the burden far exceeds that. Schizophrenia accounts for more than 380,000 emergency department visits nationwide each year.

Although antipsychotic therapy remains a fundamental component of clinical care for schizophrenia patients, poor adherence to prescribed therapy persists as a chronic obstacle. What’s worse is that caregivers and patients see the burden of side effects differently. Doctors typically underestimate how antipsychotic therapy influences anxiety and schizophrenia symptoms.

By appreciating these symptoms and engaging patients and caregivers in discussions regarding adherence, mental health clinicians can help improve outcomes for patients.

Schizophrenia’s Burden

Schizophrenia median incidence is 15.2/100,000 persons. It occurs more frequently in men than women, with a ratio of 1.4:1. Prevalence estimates also reveal prominent variation, with a median lifetime morbid risk for schizophrenia of 7.2/1,000 persons, and a roughly 1 percent lifetime risk of developing the disorder.

Schizophrenia patients have a two to three times greater mortality risk compared to the general population.

The burden of schizophrenia is heavy. And its broad influence weighs on the patient’s quality of life, crippling productivity, and accelerates the patient’s risk of self-harm or injury, and the constant risk of treatment-related adverse events. And, obviously, it’s a burden that caregivers share.

When compared to other psychiatric illnesses, the cost of schizophrenia is disproportionate to the frequency of the disease, accounting for nearly a quarter of the total cost of management of all mental illnesses (22 percent). These disproportionately higher costs suggest a need for a better grasp of adverse events associated with treatment that threaten therapy adherence.

Management Gaps

In a multinational survey of nearly 900 clinicians treating more than 6,500 patients with schizophrenia across the United States and Europe, researchers identified major gaps in treatment.

Physicians reported that both typical and atypical antipsychotics just aren’t enough to manage negative symptoms in more than 70 percent of patients.

Roughly three-quarters of clinicians  – 71 percent to 77 percent –  noted that they weren’t able to sufficiently manage negative symptoms. While about half of patients – 47 percent to 60 percent – living with positive symptoms showed inadequate control.

Even though an estimated one-third to three-fourths of patients take conventional or atypical antipsychotics, half of them battle unemployment. And the treatment comes with a high burden of side effects, especially sedation, weight gain, and movement issues.

Physician Vs. Patient Perceptions

Disparities in physician and patient understanding of the burden of adverse events tied to atypical antipsychotic drugs for schizophrenia management remain a major barrier to discussion and better management.

In one study of 42 patients taking atypical antipsychotic medications, including 17 schizophrenia patients, the relative importance of clinically important or bothersome adverse events differed substantially between patients and clinicians.

Among psychiatrists, all of the psychiatrists surveyed agreed that metabolic syndrome, weight gain, and reduced sexual desire or performance appeared to be the most clinically important adverse events, with weight gain believed to be the most bothersome symptom to patients.

Among schizophrenia patients, the most annoying adverse events diverged from those that psychiatrists expected. Although 71 percent of patients reported weight gain as a bothersome adverse event, less than half of patients – 41 percent – agreed.

Most patients – 81 percent   –pointed to low energy as a “bothersome” adverse event with 35 percent of patients rating low energy as the most bothersome symptom. Thirty-five percent of schizophrenia patients rated anxiety as the most bothersome side effect of therapy, while 24 percent saw increased positive symptoms the same way. None of the surveyed psychiatrists, however, considered these clinically relevant.

Strategies for Improving Adherence

Given that about half of schizophrenia patients walk away from treatment early in therapy, understanding the motivations behind this remains crucial to improving adherence. Although worsening symptoms account for about a third of treatment discontinuations, poor medication tolerability accounts for roughly 12 percent of dropouts.

To boost adherence, researchers have proposed several strategies, including:

• Simplifying regimens: Modifying therapy from daily medications to monthly intramuscular injections can circumvent memory lapses and prevent misunderstandings.
• Motivational interviewing: Discussing treatment goals in the context of schizophrenia and the importance of treatment adherence to meet those goals can be a powerful intervention to facilitate adherence.
• Discussing patient beliefs: Assessing and addressing patient beliefs about antipsychotic medications may address stigmas or inaccurate perceptions regarding the efficacy or safety of therapy.
• Engaging family: Family communication can be an important element of ensuring patient adherence, as caregivers and family members may follow up frequently with patients, remind patients of the need to take medication, and support patients.

Conclusions

Nonadherence with antipsychotic therapy among schizophrenia patients remains a chronic clinical management challenge. Among the factors that drive poor adherence, clinicians must recognize gaps in understanding of patient experiences of therapy vs. clinician perceptions.

By appreciating some of the effects of antipsychotic treatments on patient symptoms, clinicians can engage patients and caregivers in more productive discussions regarding adherence and the importance of long-term persistence with antipsychotic therapy to make the best of clinical outcomes.

Further Reading

Treatment-Resistant Schizophrenia: Evaluation and Management

Managing Weight, Metabolic Syndrome, and Diabetes in Schizophrenia Patients

Xanomeline-Trospium Shows Promise in Schizophrenia with Fewer Side Effects