Provider News Fall 2015 - Schizophrenia

Schizophrenia treatment

By Dr. Shepard Greene, MD, Chief Psychiatrist, Shasta County HHSA

I was asked by Andrew Deckert, MD, MPH, Shasta County Health Officer, to write a short article on the management of schizophrenia for primary care providers. Dr. Deckert recognizes that many of you are managing such patients without the benefit of psychiatric consultation for a variety of reasons. I would suspect that the majority if not all your patients with schizophrenia are fairly stable on their current medication regimen. But what if their condition somewhat goes south? In my experience, attempts to "reality test" with these patients is often counterproductive. Using logic to explain or teach them that their experiences are not valid, or not based on reality, often undermines the therapeutic relationship.

Anosognosia - "lack of insight" or "lack of awareness" - is common. Approximately 50% of my patients with schizophrenia (and bipolar disorder) do not take their medications. Impaired awareness of illness is a strange thing. To others, psychiatric symptoms seem so obvious it’s hard to believe the person experiencing them is not aware he/she is ill. Oliver Sacks, in his book "The Man Who Mistook His Wife for a Hat," noted this problem: "It is impossible for patients with certain right-hemisphere syndromes to know their own problems.... And it is singularly difficult, for even the most sensitive observer, to picture the inner state, the ‘situation’ of such patients, for this is almost unimaginably remote from anything he himself [or she herself] has ever known."

When psychotic symptoms become exacerbated or re-emerge, it’s usually not due to loss of medication efficacy but rather noncompliance with medication. Patients will convincingly declare that they are compliant with medication when they are not. I am a firm believer in using long acting injectable (LAI) medication when noncompliance is suspected. There are two widely used LAIs: Invega Sustenna (paliperidone) and Abilify Maintena (aripiprazole). Invega Trinza (paliperidone) is given once every 3 months. When considering treatment options, LAIs remove the question of noncompliance from the possibilities of decompensation.