Schizophrenia: Quality of Care & Relapse Prevention

John M. Kane, MD: Just thinking forward, how do we think we should be enhancing the training of the next generation of psychiatrists? We’ve talked about teaching them how to use clozapine and how to use long-acting injectables [LAIs]. What other areas do you think we need to help them focus on?

Jeffrey A. Lieberman, MD: I think that the next sort of need or wave is in models of mental health care that are population health focused. The models that have historically been trained on are all physician centric. They’re not standardized in a uniform way, and they’re also not uniformly represented and distributed geographically. And so you have this tremendous fragmentation and variation in the type and quality of care. Everybody talks about access. It’s not just access; it’s also quality. And we train psychiatrists in our residency programs to be able to provide treatment for different conditions and different modalities. But when they go out to jobs, that’s not necessarily what they’re going to do in the same level of emphasis. In order to be able to provide population mental health, there’s going to have to be more diversification with different paraprofessionals and team-based approaches. Those haven’t been fully developed, and they’re certainly not being trained on that in graduate schools.

John M. Kane, MD: Scott, what about technology? Do you think that’s going to play a role in helping us to improve disease management?

T. Scott Stroup, MD, MPH: There’s a lot of interest in mobile health technologies, and I think there’s a potential role. There are people using smartphones to remind people to take their medications. We’re trying to test a way to help adjust medication regimens optimally.

John M. Kane, MD: Also monitoring speech, activity, and sleep.

T. Scott Stroup, MD, MPH: To predict relapse, so people could figure out when someone needs an intervention.

John M. Kane, MD: Yeah.

T. Scott Stroup, MD, MPH: This is a little bit related to what we were talking about a minute ago, but when you were bringing up ACT [assertive community treatment], I know there’s another way to sort of make sure people get clozapine or make sure they get shots. Have performance standards for clinics, or ACT teams, or coordinated specialty-care teams to make sure that every team can prescribe clozapine or can give shots or whatever, just in the same way we want them to deliver psychosocial programs. So I think that’s 1 way to move it forward. And then you can make residency programs and train people how to use clozapine or shots.

John M. Kane, MD: Right. That’s very important. This has been an extremely informative discussion. Before we end, I just want to make sure that you have an opportunity to express any final thoughts about what we’ve been discussing.

T. Scott Stroup, MD, MPH: It’s been a good opportunity to discuss what I think is an important treatment modality. I’m honored to be here with these people who really know the field well. So thanks for letting me participate.

John M. Kane, MD: Thank you. Jeffrey?

Jeffrey A. Lieberman, MD: I’m really honored to be here. I think that despite the fact that mental health care is still not adequately provided and [improving] society in a way that it could, it’s a very optimistic time. It’s not that we don’t have the knowledge to be able to provide care, but we don’t have the means to do it. And so, what that means is that we could really up our game substantially by doing what evidence has demonstrated, which is to be using treatments like clozapine or LAIs more, and by doing the kind of education for people up front, so that it’s not viewed as a penalty for having been noncompliant and bad before, and by optimizing the way in which the evidence-based treatments can be used best.

If doctors have some reticence, that a nurse is made available, or that if there is some kind of ideological bias against the use in terms of trying to educate and orient clinical staff and mental health care teams in a way…I think there are a lot of ways in which the quality of care could be improved substantially without learning or discovering anything new through research, but just by taking the means that we have. So I feel that’s really an optimistic thing. We just need to find the social, political, and professional will to find a way to do it.

John M. Kane, MD: We’ve talked a lot about adherence and relapse and hospitalization. And I think we said that we do have some very valuable options, some very powerful tools, but we need to really take advantage of. We need to understand what the obstacles are. We need to make sure that people are trained, that we have the right systems in place, and that we have the right ancillary teams working together. But at the end of the day, even while we’re waiting for further breakthroughs, we could be doing a lot more to improve the lives of our patients if we can bring some of these lessons to bear.

I want to thank you all for your contributions to this discussion. On behalf of our panel, we thank you for joining us, and we hope that you found this Peer Exchange discussion to be useful and informative. Thanks very much.

Transcript edited for clarity.