Mr. K, age 34, has been hospitalized 4 times in 5 years for acute exacerbations of schizophrenia caused by medication nonadherence. This time he reports he discontinued antipsychotic therapy because he was “tired of taking medications every day.”
He spent 2 weeks in the acute inpatient psychiatric unit and restarted olanzapine—titrated to 15 mg/d—to which he responded well. When he presented to our outpatient clinic for follow-up, Mr. K reported adhering to his medications and denied positive symptoms. He complained of mild daytime sedation but no other side effects.
Schizophrenia patients spend most of their lives stable, rather than hospitalized for acute psychotic episodes. While stable, they continue to require close attention, and medical issues are particularly important during this time. Outpatient maintenance—such as optimizing antipsychotic therapy, offering psychosocial interventions, and monitoring physical health and well-being—provides opportunities to improve the course of illness for patients such as Mr. K.
This article describes a 7-point checkup to keep schizophrenia outpatients stable. It can help you maintain or improve patients’ function, prevent relapse, and monitor for adverse effects (Table 1).
Table 1
7-point checkup for assessing the stable schizophrenia patient
| 1. | Evaluate positive, negative, and cognitive symptoms |
| 2. | Monitor level of adherence |
| 3. | Evaluate weight, cardiovascular risk factors, and other medical parameters |
| 4. | Examine for extrapyramidal symptoms or tardive dyskinesia |
| 5. | Evaluate for comorbid mood symptoms and substance use |
| 6. | Look for prodromal symptoms that may signal relapse |
| 7. | Evaluate psychosocial interventions |
1. Symptom clusters
For several years, Mr. K worked as a research technician in a university lab, maintained an apartment, and attended to activities of daily living while taking olanzapine, 15 mg nightly. After discontinuing his medication, he reported auditory hallucinations, paranoid delusions, ideas of reference, and grossly disorganized thinking and behavior. He also was using marijuana daily, which exacerbated his psychotic symptoms and paranoia.
Addressing schizophrenia’s symptom clusters (Table 2) is key to improving patients’ social and occupational function and quality of life. Mr. K no longer has hallucinations, delusions, or disorganized thinking or behavior, but our evaluation shows his improvements are limited to schizophrenia’s positive symptoms.
Table 2
Schizophrenia’s 4 symptom clusters*
| Positive symptoms | Delusions, hallucinations, disorganization |
| Negative symptoms | Blunted affect, alogia, avolition, anhedonia |
| Cognitive symptoms | Attention, memory, executive functions (such as abstraction) |
| Affective symptoms | Dysphoria, suicidality, hopelessness |
| * Interaction of symptoms contributes to social and occupational dysfunction and adversely affects work and interpersonal relationships and self-care. | |
Cognitive symptoms. Mr. K’s concentration, attention, and memory are impaired, which interferes with his work. His ability to abstract is not impaired.
Affective symptoms. Mr. K denies signs or symptoms of depression, mania, hopelessness, or thoughts of wanting to hurt himself or anyone else.
Because antipsychotics do not adequately treat negative and cognitive symptoms, we will address these symptom clusters with psychosocial interventions.
2. Adherence
Nonadherence to medication is the most common cause of relapse and rehospitalization for patients with schizophrenia.1 We find the following strategies helpful when encouraging, maintaining, and monitoring adherence to medications.
Normalize adherence and enlist patient participation.
We inform Mr. K that most patients have trouble taking medications every day and ask how he remembers. Brainstorming with patients on ways to remember to take medications increases their likelihood of participating.
Try reminder strategies. Recommend pillboxes, alarms, and other aids. Consider enlisting family members to help patients remember to take their medications every day.
Monitor prescriptions. We limit Mr. K’s prescription to 1 month so that we can assess the timeliness and consistency of refills.
Educate. Emphasize the link between adherence and wellness, and nonadherence and relapse-—which Mr. K has clearly demonstrated. We repeat this lesson on multiple visits and counsel any involved family members as well, so that everyone understands the importance of adherence to the patient’s continued well-being.
Look for signs of nonadherence. Because Mr. K discontinued his medications without telling his physician, we remain vigilant for signs of nonadherence—such as reemergence of hallucinations, delusions, paranoia, or ideas of reference—or sudden disappearance of a side effect—such as daytime sedation, which he has consistently reported with olanzapine.
Discontinuation rates in the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) suggest that many stable schizophrenia outpatients are dissatisfied with their medications. Most patients in all treatment groups changed their medications during the 18-month National Institute of Mental Health-sponsored trial.2
SGAs versus FGAs. Schizophrenia patients may be more likely to tolerate second-generation antipsychotics (SGAs) than first-generation antipsychotics (FGAs) because of FGAs’ higher risk of movement side effects such as akathisia. Some data suggest that patients find SGAs more tolerable overall, leading to lower discontinuation rates.3