Institutional Best Practices for Treating Schizophrenia - Episode 17

Schizophrenia: Practice, Patients, and Treatment

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A panel of experts in schizophrenic psychiatric care share their thoughts on the practice, patients, and treatment based on their years of experience.

Peter Salgo, MD: What I want to do is go around to each of you and let you speak directly to the audience for 30 seconds to a minute and leave them with some pithy thought that you’ve had over the past hour and a half from the past decade or 2. I want to leave time for that before we go. Let’s start with you, Henry.

Henry Nasrallah, MD: My closing remarks are as follows: I wish that we, in psychiatry, adopt evidence-based practices for the sake of the patient. We have to stop doing the traditional same old, same old, which is often done in patients with schizophrenia, and start thinking of it as an acute emergency—a brain disorder that needs to be treated just as seriously as a stroke or a heart attack—and the only way to stabilize patients with schizophrenia on an ongoing basis, at least the majority. It’s a heterogeneous disorder, I admit to you. We estimate there are at least 800 types of schizophrenia, genetic and nongenetic. Fortunately, 70% of them respond to dopamine antagonist, which is what the long-acting injectables [LAIs] available are. 

We can manage the patient, keep them well. We need to change the habit of giving them pills when they’re discharged from the hospital only to see them come back again and again, and to think this is the way it is with schizophrenia and accept that disability as a fact of life. This is the worst thing you can do for a patient, to expect negative outcomes. I tell my colleagues in psychiatry, how would you treat your own son or daughter if they develop an acute psychotic episode with schizophrenia? How would you treat them based on the best evidence we know these days? Would you treat them differently from the patients? 

Shouldn’t you treat everybody the same, which is to protect them from the hazards of relapse as early as possible, not dillydally and wait for the patient to have multiple relapses and then use long-acting? By then they are disabled, they’re homeless, they’re incarcerated, they may have committed several suicide attempts, and they’re treatment resistant. All those negative things that can happen, most important the disability. They are written off. They have no life anymore. Wouldn’t you want to treat your son or daughter in a different way from how you’re treating your patient? I would ask them that question, knowing what they know about LAIs.

Peter Salgo, MD: Rahn, you’re up.

Rahn Bailey, MD, DFAPA: First of all, great panel. Thank you to the moderator and both of my copanelists. I’ll end with some pithy statement that I started with. This stigma has raised its head throughout my career, and that in many regards is at the foundation of today’s discussion. Stigma very often refers to fear; it’s unrealistic. It’s not based on fact, but it’s perpetuated in an ongoing fashion, and that’s a reasonable consideration for today’s discussion of why it’s so difficult to make the argument, to clinicians, patients, and families, why we should use an empirically based approach and do what’s best for the patient clinically short term and long term.

There’s more. There’s also this idea that, as physicians, there’s stigma within our own profession. This last comment that Henry makes is timely. Much of my career…. You go away and stop all your medications as if the other clinicians and physicians in health care think our medicines don’t matter or that they’re doing something to actually prevent mortality in human beings whose lives are as important to me as they should be to them if that patient has heart disease, diabetes, asthma, cancer, or something that’s a component there as well. It’s likely that other individuals, including other physicians and clinicians, are also sending the same message that one shouldn’t take the medication—you shouldn’t take the injections; you shouldn’t need medication. They’re noncompliant; you don’t really need this. Nothing is wrong with you. We’ve got to make that argument much more effectively.

I’ll end with my comment of my mother. To be a doctor you have a good therapeutic alliance. The bedside manner was always what she talked to me about. I have a daughter who’s a doctor, but I always say the smartest doctor in our family was the one who was a schoolteacher: my mother. It made so much sense. At this time in my career, I’ve appreciated that if patients believe in me in many regards and what I represent, if they trust and believe in the doctor, then they’ll trust and believe in our message. Then they’d arguably be more likely to be compliant. Compliance can also occur with LAIs, and they just happen to be with oral treatment. Today’s discussion was remarkably timely for my patient population and 1 that we all should take to heart. We had a very good session. Thank you for having me.

Peter Salgo, MD: Joe, this is either very good or very bad. You’ve got the last word. Did they take all the good stuff, or do you have something pithy to say?

Joe Avelino, RN, BSN, MHSA, CPHQ: Actually, I’m going to begin with LAIs and close with LAIs. This surge of people experiencing psychiatric problems has the potential to impact the health care system for years to come. What I’m talking about is the pandemic has not only interrupted the treatment of people managing mental or substance abuse disorders but has also placed broader segments of the population at risk for developing conditions, such as depression, anxiety, alcohol use disorder, and as Henry alluded to earlier, post-traumatic stress disorder, PTSD. After 25 years in the military, the challenges with PTSD are still forthcoming.

But let me close with this, because we started with LAIs: As our distinguished panelists Rahn and Henry alluded to and you facilitated, Peter, LAI is our hope for the future. We take it for granted, and it’s underutilized. Better education of LAIs for our psychiatric population is certainly a sign of hope.

Peter Salgo, MD: I want to thank all of you. This has been a tremendous discussion. Because I’m not a psychiatrist, there was a lot of new information, all of which was hopeful. I didn’t expect it to be. This was great stuff. I want to thank all of you at home, of course, or wherever you’re watching this HCPLive® Peer Exchange broadcast. If you enjoyed the content, we invite you to subscribe for our e-newsletters to receive upcoming Peer Exchanges and other great content right in your inbox. I’m Dr Peter Salgo. Thank you, and I’ll see you next time.

Transcript Edited for Clarity