Institutional Best Practices for Treating Schizophrenia - Episode 3
Henry Nasrallah, MD, examines schizophrenia relapse, specifically how to diagnose and prevent it before further damage has transpired in the patient’s brain.
Peter Salgo, MD: Let’s take a look at a different issue here, which is we’ve made the diagnosis, we’ve integrated a patient into the system, perhaps the patient is getting therapy. But patients with schizophrenia relapse, and they’re often relapsing away from the doctor’s office and away from the setting in which they’re observed carefully. How do you diagnose the relapsing schizophrenia in patients?
Rahn Bailey, MD, DFAPA: For me, relapse is indicated when a person is discharged, they’ve met all the criteria for discharge, they’re stable, and then they can’t get to a period of 6 months free of symptoms, and they have a fulminant return of symptoms. If we can make an immediate response, if they just got off their medication and can respond quickly, so be it. But very often in that setting, I like this idea of what we call “downward drift.” Every time there’s a relapse, the patient gets worse, and it’s more difficult to have them respond and for them to get better, so they go back to the hospital. I like to teach my residents and trainees that they may not get right back on the exact same medicine, same pills, that doesn’t always work very well for them. Importantly, the relapse is a component of the process, and our goal has to be to provide care and treatment to increase the likelihood that when they get out of the hospital, they have all the wrap-around services it entails, along with medication management, so they’re less likely to relapse. Relapsing consistently bodes adversely for long-term prognosis.
Peter Salgo, MD: It seems to me like there are 2 consequences to a relapse, based on what you just said. One, to the patient, which is if you relapse, they may never get back to their previous state or it may be difficult to do that, and that’s a disaster for the patient. Then there’s also the problem for the entire health care delivery system. If patients are relapsing, then they’re using a tremendous amount of resources and money, and it’s very expensive, isn’t it?
Joe Avelino, RN, BSN, MHSA, CPHQ: Henry commented earlier about how crucial getting the family and significant others involved is, educating them even in the discharge planning process, getting the family involved with what resources are out there. For instance, some of these patients, at least from a hospital care setting, are not necessarily able to meet inpatient criteria, but what are some of the clinic resources? We provide that information not only to the patient, but also to their family members, which is crucial in the process. There’s no doubt that the readmission rate for patients with behavioral health issues is significantly high. Best practice out there is 17%, 18%. Fortunately for us here, it’s only 15%, but we know there’s going to be a little relapse. But to be proactive and knowing how to address it, working collaboratively not only with the patient, but with the family members, is going to be crucial in the journey.
Peter Salgo, MD: I’m assuming that adherence to medication, adherence to therapy is critical, and I’m also hearing that once you’ve had a relapse, it’s tough to get back to where you started. How does adherence to the regimen affect relapses, and then if it does affect relapses, what do we do about that, and how do we address keeping people on their regimen most effectively?
Henry Nasrallah, MD: It’s vital to educate the family, like Joe said, at the time of discharge from the hospital. Tell them what the signs and symptoms are that the patient, their son or daughter, had when they had the first episode, because it is very likely that the relapse will be associated with exactly the same symptoms. Giving them good instruction about the symptoms of relapse in their son or daughter is important, because every patient is a little different. But they recapitulate the same symptom with every relapse, that’s the first thing we should educate the family about. Then No. 2, which relates to what you just asked, the second thing we must emphasize to families is that complete adherence is vital, otherwise they’re going to have another psychotic episode. We need to educate the family that this is a brain disorder, it’s a degenerative brain disease. It’s like a stroke. Every time you have a stroke, you damage more brain tissue; it’s the same thing with schizophrenia. Every time you have another psychotic episode, there is more damage to the brain, and the chances of disability increase, and the chances of complete recovery decrease with every episode.
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Transcript Edited for Clarity