Non-psychotic Issues of Schizophrenic Patients

Chairperson: S. Charles Schulz, MD

Schizophrenia is a severe psychotic psychiatric illness. The reduction of hallucinations, delusions, and thought disorder by antipsychotic medications has been a substantial help to many people with the illness, but may have overshadowed a number of problems the schizophrenic patient faces. Many of the issues have a major effect on functional outcome, morbidity and even mortality. It was the purpose of this symposium to focus on these problems and to provide an update on current interventions. The role of cognition in social and functional outcome is now well known. Dr. Raquel Gur presented data on research on the underpinning of cognition and approaches to improving cognitive function. This presentation was followed by a review of research on smoking in schizophrenia (Dr. Hossein Fatemi). Despite a reduction of smoking in the general population, the rates and amounts of smoking in schizophrenia remain high, thus it is important for psychiatrists to understand new approaches. Similarly, substance abuse is common and can be debilitating in schizophrenia. Dr. Alan Green, a leader in this field, provided an update of physiology and treatment in this area. To conclude the symposium, Dr. Schulz presented an update to the understanding of suicide in schizophrenia. Although the rate of suicide is high in schizophrenia, research on signs and treatment has not been forthcoming. New understanding and approaches are emerging and may lead to useful interventions.

Cognitive Rehabilitation of Schizophrenia: Treatment and Research

Raquel Gur, MD, PhD

The well-established cognitive deficits in schizophrenia and their impact on functioning have led to an effort to apply remediation methods. Several systematic strategies have been applied most deriving from methods developed for rehabilitation from acute brain injury. The presentation outlined the main approached and the attempt to summarize available data on their relative efficacy. Methodological limitations and challenges will be highlighted. The advent of computerized approaches has broadened the capabilities of rehabilitative methods and can yield novel interventions with inherent capacity to document progress. The future is encouraging also from the standpoint that increased understanding of the neurobiological basis of schizophrenia can help guide further refinements and multimodal approaches that focus on impaired brain systems through combined pharmacologic and rehabilitation approaches.

Smoking and Schizophrenia: Efficacy of New Treatments

S. Hossein Fatemi, MD, PhD

There is a strong association between smoking and schizophrenia with prevalence rates ranging from 74% to 90%, versus a national average of 30% in nonschizophrenic individuals. A number of hypotheses have been proposed to explain the relationship between high smoking rates and schizophrenia, mostly relating to self-medication primarily for the negative symptoms of schizophrenia. The negative health effects of smoking increase the morbidity and mortality in schizophrenic patients. Available treatments for smoking cessation have had mixed results in this population. Method: A literature search was conducted examining the efficacy and safety of current smoking cessation treatments for schizophrenics. Results: Studies with nicotine patches have yielded a quit rate only half that of healthy subjects. The smoking cessation agent bupropion HCl has been tested in schizophrenics and appears to be safe, but the results on its efficacy are inconclusive. Varenicline, a partial a4s2 and full a7 nicotinic acetylcholine receptor agonist, is a newer smoking cessation agent. Varenicline has proven efficacy in healthy, non-psychiatric subjects and is more effective than bupropion HCl. A series of case reports have suggested that varenicline may exacerbate neuropsychiatric symptoms including changes in behavior, agitation, depressed mood, suicidal ideation, and attempted and completed suicide, in subjects with bipolar disorder or schizophrenia, leading to an FDA warning and a black box warning. However, a large study of the efficacy and safety of varenicline in subjects with mental illness found that varenicline successfully reduced smoking and led to no exacerbation of symptoms. Conclusion: Further study of varenicline in schizophrenics is needed as it may offer a new treatment for smoking cessation in this vulnerable population.

Schizophrenia and Substance Abuse

Alan I. Green, MD

Substance use disorders are common in patientswith schizophrenia and are associated with pooroutcomes. Cannabis use disorder occurs in up to 50%of first episode patients; alcohol use disorder is the mostcommon substance use disorder in patients beyond thefirst episode. The basis of such co-occurring substanceuse disorders in patients with schizophrenia is unclear.While self-medication hypotheses have been proposed,a number of studies have been unable to confirm thatself-medication of psychiatric symptoms is causally relatedto use of substances in these patients. We and others havesuggested that a dysregulation of the mesocorticolimbicbrain reward circuitry may underlie substance use disordersin schizophrenia. Research has suggested that treatment ofco-occurring substance use disorders should be undertakenin an integrated fashion, where treatment of both disorderscan be implemented by one clinical team. Evidence-basedpsychosocial interventions include stage-basedmotivational interviewing, group therapy and cognitivebehavioral therapy; in addition, contingency managementapproaches appear quite promising. The evidence-basefor pharmacologic strategies is evolving. While typicalantipsychotics do not appear to lessen substance use inpatients with schizophrenia, emerging data suggest thatsome of the atypical antipsychotics, particularly clozapine,do so. In addition, naltrexone and disulfiram have beenshown in preliminary studies to limit alcohol abuse inpatients with schizophrenia. This presentation reviewedthe characteristics of substance use disorders in patientswith schizophrenia, as well as the evidence base regardingtreatment of these co-occurring disorders. It alsodescribed on-going research in animals that is attemptingto elucidate the actions of clozapine responsible for itsapparent ability to limit substance use in these patients.

Approaches to Suicide in Schizophrenia

LawrenceAdler, MD

One percent of the population across the globe suffers from schizophrenia. Over their lifetime, ten percent of these patients will die by suicide. Almost three times as many make single or multiple suicide attempts. There are multiple risk factors that affect the risk of suicide in schizophrenic patients. Furthermore, approaches to suicide reduction or reducing long term suicide risk is not likely to be accomplished by one single approach. For example, younger age of onset increases risk of suicide. Specific pharmacologic treatments may reduce the risk of suicide. Social supports and frequency of contact with a clinician, particularly after a hospitalization, may reduce risk. Cognitive deficits affect not only social support, but ability to work, to follow treatment plans and to feel part of a community. Specific endophenotypes may also affect the risk of suicide. Thus, it is unlikely that one specific approach will reduce suicide risk in patients, but there is much the individual clinician can use to assess suicide risk and to reduce risk in treating individual patients. This presentation will review basic risk factors, recent studies, and implications for reducing suicide risk in schizophrenic patients.

Adapted from materials provided by the APA.