Questions About the Future Management of Schizophrenia

Peter L. Salgo, MD: We have some questions from our viewers, so in the little time we have left I want to throw a few of these out at you.

John M. Kane, MD: Sure.

Peter L. Salgo, MD: There’s no warning as to what’s coming, so here we go. One of our viewers asks, “What does the future look like in treating schizophrenia?”

John M. Kane, MD: Ooh.

Peter L. Salgo, MD: I told you these weren’t easy.

John M. Kane, MD: As Yogi Berra said, “It’s tough to make predictions, especially about the future.” I’d like to think that we are going to have a better understanding of the nature of schizophrenia, the pathophysiology. We know that it’s largely genetic, but there’s tremendous heterogeneity. We don’t have good biomarkers for predicting response. Much of it is trial and error, etcetera. I would also like to think that we’ll do a better job with what we’ve been talking about, that we’ll take advantage of some of the opportunities that we have. We’re also going to see better use of technology for monitoring patients, for working with patients on a day-to-day basis real time.

Peter L. Salgo, MD: Here’s an interesting question. Our viewer asks, “What is the risk of developing tardive dyskinesia using medications to treat schizophrenia. How do you manage it?” And in parentheses, there was a TV on today in my hospital and there was an ad for a medication for treating tardive dyskinesia, aimed the general public.

John M. Kane, MD: Oh, yes.

Peter L. Salgo, MD: It’s a real issue.

John M. Kane, MD: Yes. It is an issue, and it was more of an issue earlier in my career when we were working with the so-called first-generation antipsychotic drugs. In those drugs, the incidence was about 5% per year.

Peter L. Salgo, MD: That’s big.

John M. Kane, MD: That’s big. Now, with the newer drugs, it’s closer to 1% per year, in my opinion. So the newer drugs are safer. Their risk is not completely gone, but I think the risk is substantially lower. People often ask in addition, “Is the risk greater with the long-acting formulations than it is with the oral formulations?” The answer to that is no. It sometimes might appear greater if the people aren’t actually taking the oral formulations, right?

Peter L. Salgo, MD: If you don’t take the drug, you’re not going to get tardive dyskinesia.

John M. Kane, MD: That’s right, exactly. But there’s no evidence that the risk is greater with the long-acting formulations. But it is a problem. Unfortunately, many clinicians have lost track of some of the neurologic adverse effects because they’re less common now. There are 2 new drugs that have been approved recently to treat tardive dyskinesia. We never had drugs that were actually approved by the FDA to treat this.

Peter L. Salgo, MD: I think that’s what they were advertising on TV.

John M. Kane, MD: Yes, so that’s good news. We do have options now to treat it, but we’d also like to prevent it. The way we prevent it is by using antipsychotic drugs only in people where it’s clearly indicated and trying to use the lowest possible dose.

Peter L. Salgo, MD: Here’s a question. We addressed this a bit earlier. Our viewer asks, “What is the role of primary care physicians in managing comorbid conditions for a patient with schizophrenia?”

John M. Kane, MD: Well, I think it’s very important because I think the average psychiatrist is not going to treat type 2 diabetes or hypertension. What we see with many patients who have schizophrenia is that these comorbid conditions are not well managed. Many of our patients smoke, and many of them are overweight. The life expectancy for someone with chronic and severe mental illness in the United States is 20 years shorter than the rest of the population.

Peter L. Salgo, MD: Stop, 20 years.

John M. Kane, MD: Twenty years shorter, yes.

Peter L. Salgo, MD: That’s a real challenge for the primary care physician.

John M. Kane, MD: Absolutely. As you know, many primary care physicians are a little put off by people who are chronic and severely mentally ill. They don’t necessarily want them in their waiting room, so I think we have to work on that. We have to make sure that we as psychiatrists are facilitating access to primary care.

Peter L. Salgo, MD: You make them saner, and the primary care physicians have to make them better from everything else.

John M. Kane, MD: From all the medical comorbidities.

Peter L. Salgo, MD: Fair enough?

John M. Kane, MD: Absolutely.

Peter L. Salgo, MD: Here’s one. “I’m a payer responsible for negotiating contracts with the local system. How can I help to enable the use of LAIs [long-acting injectables]?”

John M. Kane, MD: Well, I think you want to make sure that you are encouraging their use, that you are paying for them, that you recognize that in the long run, it will save money. If we can avoid days in the hospital, that’s associated with tremendous cost savings for the payers and for everyone. They should have an incentive to really help educate people. Right now, we talked earlier about what’s missing and I said, “Well, there needs to be better training for clinicians on how to have these conversations.” I think the payers could help with that.

Peter L. Salgo, MD: Again, I have a personal story about not an antipsychotic drug. But I was there when Zofran was first introduced. As I recall, it was only in multiple vials, and they were like $1000. If you cracked it, you paid for it. I had a patient with severe nausea, and she was going to get admitted postoperatively if we couldn’t fix it. That was going to cost thousands. So I opened the vial, gave her 4 mg, and she went home. The overall cost saving was huge. What has to be overcome is the individual dose cost and the recognition that it’s not in isolation. It’s in the whole system cost. It seems like that to me.

John M. Kane, MD: Yes.

Peter L. Salgo, MD: Here’s another question. “In simple terms, what elements within the guidelines should be followed to guide practice in LAI use?”

John M. Kane, MD: Well, I think the guidelines need to be revised. The first thing is….

Peter L. Salgo, MD: Fifteen years is too long.

John M. Kane, MD: It’s too long. I think we need to really encourage the use of long-acting formulations and not shy away that this is somehow too controlling or too paternalistic. We’re trying to control a very serious illness.

Peter L. Salgo, MD: Right. We have a couple more. You ready?

John M. Kane, MD: Sure.

Peter L. Salgo, MD: “What role do psychosocial factors such as healthy diet, exercise, vitamins, family support play in managing schizophrenia?” Notice they didn’t say medications.

John M. Kane, MD: Yes. I think all of those things are important. Even though schizophrenia is, we believe, a brain disease and largely genetic, there are tremendous psychosocial and environmental factors that need to be addressed. People need individual therapy, they need family therapy, and they need supportive education and supportive employment. They need help finding a job, keeping a job, getting back to school, and all of those things. So it’s very important. Obesity is a problem for anyone. With someone who has a chronic and severe mental illness, it’s also a huge problem. Smoking and all the things that affect health are also going to affect the things that we’re trying to improve.

Peter L. Salgo, MD: One last question. Our viewer writes, “How do you encourage a patient who vehemently denies that he or she has schizophrenia, to seek help?” Then, “How do you bring the injection into this?” I think you answered the second part of that.

John M. Kane, MD: I think it gets back to motivational interviewing. You don’t want to struggle with someone about the diagnosis, or “What is this?” or “Am I ill or not?” You want to focus on, “OK, what do you want to do? What do you want to achieve? What are your goals? What’s missing? You can’t find a job. OK, well, what can we do to help you find a job?” It may be that the erratic behavior and the suspiciousness is preventing the person from getting a job, so we’re going to try to work through the goal to achieve what we believe is the therapeutic goal.

Peter L. Salgo, MD: What sounds really tough, and why you can have this job, because I can’t do it, I don’t think, it’s some of that paranoia and some of the fear must translate even to your questions. “What do you want to do?” “Why is he asking me?” Right? There’s a double, triple, quadruple risk here.

John M. Kane, MD: Sure. That’s the challenge of psychiatry. I think you want to establish a good therapeutic relationship with someone, earn their trust, make sure they feel comfortable having these kinds of conversations, and that can take time. But you’re also going to demonstrate that you’re going to work with them to help them achieve their goals.

Peter L. Salgo, MD: Except of all these diseases, schizophrenia is, at least in part, a disease of trust.

John M. Kane, MD: Yes. It’s true.

Peter L. Salgo, MD: Tough.

John M. Kane, MD: It’s tough, but this is where I think many psychiatrists can feel a great deal of reward because when they can have an impact on that situation, it’s very rewarding.

Peter L. Salgo, MD: It’s like Billy Joel, “It’s always been a matter of trust.” This has been a great conversation. Thank you so much for joining me.

John M. Kane, MD: My pleasure.

Peter L. Salgo, MD: I didn’t know where we were going to go with this because it’s a tricky disease, all these new therapies are interesting, and the guidelines seem out of date. Thank you so much for joining us and bringing us up to speed.

John M. Kane, MD: My pleasure. Thank you.

Peter L. Salgo, MD: All right. I want to thank you at home, too, for watching this HCPLive® presentation of “Long-Acting Injectable Medications in Schizophrenia.” I hope you found this Peers & Perspectives discussion to be useful and informative. I’m Dr Peter Salgo, and I’ll see you next time.

Transcript edited for clarity.