Counseling Patients With Schizophrenia on Relapse

Transcript: Segment Description: The importance of discussing early the risk of relapse with patients with schizophrenia to help improve adherence to therapy.

John M. Kane, MD: We don’t want to underestimate how important the diagnostic process is. How do you diagnose relapse in patients with schizophrenia and how do you discuss this with the patient and the family?

Sanjai Rao, MD: This topic hits home for me because I'm an inpatient psychiatrist. Almost every schizophrenia patient I see has relapsed, and hospitalization is the result for numerous reasons. Hospitalization doesn’t just occur. We’re trained to think of relapse as something went wrong and they got hospitalized. However, it starts before that. In the time leading up to hospitalization many patients needed additional services. They were visiting our emergency clinic or emergency department and were complaining of increased symptoms. They needed to have their medication increased, or they needed to have medications added to treat symptoms they were having. They might’ve engaged in suicidal behavior, dangerous activity, or some of them get arrested or incarcerated.

There’s a constellation of things that leads up to the full decompensation before hospitalization. The most relevant one is that many of these patients will stop their medication. This is the most proximate cause to them being hospitalized. They will say they stopped because it wasn't tolerable, or quite often because it wasn't working for them, or they were taking it intermittently or maybe they just missed a couple of doses. This makes them spiral in a way that caused them to stop their medication completely. Oftentimes I see patients when the crisis is bad enough that they have been hospitalized. In this setting, I'm discussing their relapse with them as they are in the worst state. After the initial stabilization, if someone is grossly psychotic, you're not going to be able to have an impactful discussion with them.

Once they are stabilized to the point where they can have a conversation with you, I find that the most important thing you can do is figure out what they actually want out of their treatment. What are their treatment goals? What do they want to do when they leave the hospital? Do they want to leave the hospital? Do they want to have a job? Do they want to have a relationship? Is there life outside their illness that will drive their motivation to get treatment?

Once we identify those, we talk about relapse in a way that aligns with patient goals. For example, if they want to get a job, then we can talk to them about how having repeated relapses is probably going to keep them from keeping a job. If they're able to find a job, they need to maintain stability or they're not going to be able to keep that job. If they are functional and have the cognitive capacity to hear it, we discuss the long-term consequences of relapse. Each time they relapse, or the amount of time they spend untreated, will lead to lower overall functioning in the long term. It may be damaging their brain or reducing brain volume.

Henry A. Nasrallah, MD: What you described is a clinical observation that leads you to recognize relapse. In research, we define relapse in a very structured way, using the rating scales, the positive and negative symptom scale. An increase of 25% [on the scale] is classically seen as a relapse, or an increase in the delusions, hallucinations are another sign of relapse. For relapse in a patient who was already treated, seems to be stable, and now they are re-experiencing symptoms, oftentimes it’s a recapitulation of the same symptoms they had when they came in for the first psychotic break. This is an easy way to identify that they relapsed.

Sanjai Rao, MD: One big question they always have is what is this medication going to look like in me? How is it going to affect me? What am I going to feel like on it? With the fear that the medication is going to change who they are, change their mind, make them feel like a zombie, these are questions we hear from patients.

It’s important to reassure them that our treatment goal is not to change who they are, but to have the most tolerable and realistic medication regimen that we can put them on that will control their symptoms but also be reasonable enough for them to comply with and to take long term.

John M. Kane, MD: Those are very important points, and it can be difficult for patients to accept the need for a long-term medication treatment. It's often a challenge. Erin, what is your sense about this issue, and how a relapse can affect the mental well-being of a patient?

Transcript Edited for Clarity