Challenges in Identifying and Treating Schizophrenia

Peter L. Salgo, MD: Welcome to this HCPLive® Peers & Perspectives® presentation titled “Recommendations on Optimal Treatment for Schizophrenia.” I’m Dr Peter Salgo. I’m a professor of medicine and anesthesiology at NewYork-Presbyterian Hospital and Columbia University Vagelos College of Physicians and Surgeons in New York, New York.

Schizophrenia is a complex, long-term medical illness. It affects about 1% of Americans and interferes with a person’s ability to think clearly, make decisions, and relate to others. Today we’re going to talk about some of the challenges of treating schizophrenia and the benefits of long-acting injectable medications in these patients. To discuss these challenges, I am pleased to be joined by Dr John Kane. He’s a professor and the chairman of psychiatry at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. Welcome. Let’s begin.

John M. Kane, MD: Thank you.

Peter L. Salgo, MD: Why don’t we start with the obvious question, at least obvious to me. What is schizophrenia? I think the public has a different appreciation than we do.

John M. Kane, MD: Yes, you’re right. Many people think it means split personality, but it’s actually an illness that affects about 1% of the population, as you said. It tends to begin in late adolescence or early adulthood. It affects the way people think and the way they perceive reality. Some people may have hallucinations—hearing a voice when there’s no one speaking—delusions which are fixed false believes that someone cannot be talked out of, suspiciousness, difficulty in social interactions, difficulty with some cognitive tasks, and in many cases, a lack of motivation or a lack of pleasure capacity.

Peter L. Salgo, MD: I’ve seen a bumper sticker, and I’ll bet you’ve seen it too. “I have schizophrenia, and so do I.” I think this is all that misconception about multiple personalities.

John M. Kane, MD: Yes.

Peter L. Salgo, MD: Where did that come from?

John M. Kane, MD: I guess the word schizo means split, so I think it’s derived from that to some extent. But many people have the notion that mental illness means multiple personality. Obviously, that’s a very rare form of mental illness, and schizophrenia is much more common and quite different.

Peter L. Salgo, MD: Have you ever seen it, multiple personalities?

John M. Kane, MD: I never have. I’ve read books about it.

Peter L. Salgo, MD: I’ve read about it too. Mind you, I’m not a psychiatrist. I’ve never seen it.

John M. Kane, MD: I’ve never seen it.

Peter L. Salgo, MD: I wonder if it really exists. That being said, 1 of the things about doing this job is I get to sit in front of an expert and ask the questions I’ve wanted to ask for 20 years—I just did it. That being said, let’s go on to the medical challenges that this disease presents, because this can be a serious medical problem. What are the challenges that this disease presents to a practitioner?

John M. Kane, MD: I think the first challenge is actually early identification and engagement in treatment. Most people who develop a psychotic disorder like schizophrenia don’t initially recognize that there’s anything wrong. This is because if they’re having a delusion or they’re hearing voices, they think they’re real.

Peter L. Salgo, MD: People have told me that that they feel that this is real.

John M. Kane, MD: Right. So they don’t see it as a problem. They don’t see it as a medical problem, and it’s often not until it leads to some difficulty like behaving badly in public or getting into a fight with someone that the person gets into treatment. Treatment often begins when someone is brought to a hospital emergency department and sometimes by the police. One of the challenges is what can we do to educate the public, so that mental illnesses like schizophrenia can be recognized earlier in their course. In the United States right now, the duration of untreated psychosis—meaning the time between somebody experiencing the onset of psychotic symptoms and actually getting to treatment—is more than a year.

Peter L. Salgo, MD: More than a year.

John M. Kane, MD: Yeah. Think about someone in the community experiencing delusions, hallucinations, and disturbances in thinking and not getting any treatment. We believe this actually has consequences in terms of how someone will respond to treatment once it is delivered.

Peter L. Salgo, MD: I don’t mean to say you’re being glib, but isn’t it facile to say, “Gosh, if only these people saw these obvious symptoms and they got him help or her help?” By the way, what’s the split, male versus female?

John M. Kane, MD: It’s about equal. The illness tends to be a little more severe in men, as is the case with many brain diseases.

Peter L. Salgo, MD: It’s so easy to sit here, both of us, and say, “Gee, you know, the family, the friends, the school, the job—why didn’t you do something?” But my sense of this is that it’s more subtle than that. The onset is not abrupt sometimes, and the symptoms are subtle until something happens. Is that fair?

John M. Kane, MD: I think it’s fair, but I think there is an element that the public lacks mental health literacy—that people don’t understand what mental illness is. They’re very reluctant to intervene. Even when someone is severely depressed and we see that it’s a problem, or when someone has severe alcoholism and we recognize that it’s a problem, we’re often reluctant to intervene. I think that’s in some ways a societal problem. For us as clinicians and as psychiatrists, we’re trying to think of ways we can help engage people earlier.

Peter L. Salgo, MD: It reminds me of Annie Hall, when they’re discussing the alcoholic brother, and they go, “Oh, look at this guy, you know him.” And he’s having these delusions in front of Woody Allen. He’s saying, “I have these delusions of ‘I’m going to drive my car on a rainy night off the road.’ ” They go, “Oops, he’s just our brother,” when he needs help.

John M. Kane, MD: Yes.

Peter L. Salgo, MD: We haven’t even gotten into this, but is schizophrenia is a disease that can be recognized by a nonpsychiatrist, by a family practitioner? And if so, can a family practitioner treat it?

John M. Kane, MD: I think the answer on average will be no. The average family practitioner is not trained to make a differential diagnosis of a psychotic disorder. I think they could certainly pick up some early signs and then refer the person to a psychiatrist. In my opinion, this is an illness that really does require a specialty care. There may be a point in time, however, when someone is stabilized, they’re on medication, and they need someone to help give the injections.

Peter L. Salgo, MD: I was going there. Can they pick up from you and just follow the patient?

John M. Kane, MD: Yes, I think they can. You still want a collaborative care with a psychiatrist. We need family practitioners and internists to help us manage the type 2 diabetes that might occur or the obesity.

Peter L. Salgo, MD: You mean there are comorbidities in people?

John M. Kane, MD: There are comorbidities.

Peter L. Salgo, MD: I’ve never heard of a patient with more than 1 disease.

John M. Kane, MD: Absolutely.

Transcript edited for clarity.