Challenges in Treating Schizophrenia

Transcript: John M. Kane, MD: I'm Dr John Kane from the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in New York. In this HCPLive^® Peer Exchange we are discussing optimizing management of schizophrenia with long-acting injectable antipsychotics. Joining me today are my colleagues, Erin Crown, [physician assistant-certified] from Oasis LifeCare, Pennsylvania; Dr Henry Nasrallah, University of Cincinnati College of Medicine; Dr Sanjai Rao, from the University of California San Diego; and Dr Dawn Velligan, from the University of Texas Health Science Center in San Antonio. Today’s focus is on the use of long-acting injectable antipsychotics to help manage schizophrenia, increase treatment adherence, and prevent relapses.

Dawn, what are some of the challenges and unmet needs that you face when you're treating patients with schizophrenia?

Dawn I. Velligan, PhD: There are a lot of challenges that we haven't addressed well. First of all, treatment adherence is a big issue. We make home visits and we see bottles of medications that they haven't taken. It isn't good for their recovery if they're not on stable medication; it's difficult for them to build the foundation for recovery. The second thing would be negative symptoms, lack of motivation, and being anti-social. There aren’t good treatments for that. It's difficult to get people moving and doing, who have negative symptoms. We don't have treatments for cognitive impairment. People have trouble with attention, memory, planning, and judgment. We don't have treatments available to help with this. These are some of the unmet needs that I see.

Henry A. Nasrallah, MD: One of the challenges I face with a lot of my patients and their families is that they are ignorant about the illness at the onset. They have no idea how serious it is. They do not understand that this is lifelong even though we educate them about the illness being long term with potential relapses unless the patient adheres. Many families have absolutely no idea what schizophrenia is. There is a lot of education to be done at the beginning.

John M. Kane, MD: That’s a good point, Henry. How about the differential diagnosis of schizophrenia?

Henry A. Nasrallah, MD: Yes, schizophrenia is now regarded as a spectrum, a huge spectrum probably comprised of hundreds of diseases, that look alike clinically, similar phenotypes but different genotypes. In the differential diagnosis of the psychosis spectrum itself, we consider schizophrenia, schizoaffective disorder, delusional disorder, brief reactive psychosis, and drug-induced psychosis.

The DSM [Diagnostic and Statistical Manual of Mental Disorders] encourages us to rule out 2 things before we jump into a primary diagnosis of psychosis or schizophrenia. Is it due to substance use, or is it due to a general medical condition? There are numerous substances, both prescription drugs and nonprescription drugs of abuse, that can cause schizophrenia. There are also numerous medical conditions, especially brain disorders and neurological conditions, like epilepsy or brain tumor or metachromatic leukodystrophy, which can look exactly like schizophrenia. Or even frontotemporal dementia, early onset can look like schizophrenia. You can look at all the endocrine disorders, infectious disorders, heavy metal poisoning, and autoimmune disorders. There are a lot of conditions, even severe nutritional deficiency can cause what looks like schizophrenia or psychosis. Psychosis is a different diagnosis.

John M. Kane, MD: It’s important to rule out other potential etiologies, but when we look at the majority of patients who present to us, our diagnostic criteria are pretty valid and reliable, wouldn’t you say?

Henry A. Nasrallah, MD: They are more reliable than valid, I think. The DSM has helped us replicate each other in terms of the reliability of diagnosis[MV1] . I'm not sure that the validity is still there. We need to move into biomarkers that identify the various mild types of schizophrenia. We are making progress. At this time, we are dependent on a cluster of symptoms that we regard in the DSM as diagnostic.

Transcript Edited for Clarity