September 2007: Monitoring patients with schizophrenia
Schizophrenia is a heterogeneous condition and commonly presents in patients aged 20-30 years, but may present in teenagers.
Patients almost always require some form of intervention to prevent harm and alleviate suffering. Schizophrenia is one of the top ten causes of disability according to the WHO Global Burden of Disease.1
Schizophrenia affects one in 100 people in the UK at some time in their lives. Around one in five of these patients will only have one schizophrenic episode.2 Seven in ten will have two episodes, usually occurring within 5-7 years of each other.
The course of illness varies, both in the length of time and quality of recovery between episodes. Some patients develop a chronic and disabling course; however, even in this group most patients will improve with treatment.
Many patients now strive to find ways of living satisfying lives even with the limitations caused by illness.3
Schizophrenia is believed to be a neurodevelopmental disorder. There is no single cause, but both genetic and environmental factors play a role.
First-degree relatives of patients have a five- to 10-fold increased risk of developing the condition.4
Environmental causes include prenatal exposure to influenza and fetal hypoxia, but the effect sizes are small.5,6
The relationship between schizophrenia and substance misuse is complex. Although illicit substances may not cause schizophrenia, they may trigger an episode and certainly complicate its management.
When should GPs suspect schizophrenia?
Schizophrenia is diagnosed according to the International Classification of Diseases
(ICD-10) or US Diagnostic and Statistical Manual (DSM-IV) criteria.7
In the early stages of the illness, patients may appear odd or different. They may lose interest in ordinary activities (work, studies, hobbies) and relationships, and their ability to function daily may deteriorate. Others may notice changes before the patient becomes aware of them.
Patients may present withdrawn, depressed or anxious and some may misuse substances. Without treatment their symptoms will become more obvious. See table 1, attached.
What is the role of the GP in managing patients with schizophrenia?
All patients should have a comprehensive assessment when first diagnosed. This should examine a range of areas, including the patient's health, social, occupational and psychological needs.
A care plan should be developed and the patient should be reviewed regularly.
The GP's role is to inform the keyworker of changes that may affect the patient's wellbeing. The keyworker is the contact person working in secondary care; usually a community psychiatric nurse. The role of healthcare professionals will vary depending on local service configuration.
The GP should have contact instructions for out-of-hours or crisis interventions.
GPs should be kept informed of admissions, discharges or changes in risk (for example suicide risk, vulnerability or risk to others) or treatment.
All patients should have their mental and physical health reviewed annually. This will usually be done by secondary care services, but some patients may be unwilling to see a psychiatrist. Patients with schizophrenia often suffer from poor physical health and GPs should monitor and treat concurrent health problems.
When should patients be referred and to whom?
Referral should occur:
• At the time of diagnosis. If acute symptoms are present, NICE recommends that GPs should consider starting an atypical antipsychotic and refer the patient to secondary care urgently
• Early in relapse. Early intervention is vital to reduce risks and shorten the length of an episode
• If there is poor response to treatment, poor adherence to treatment or ongoing side-effects
• If there is poor functioning and subsequent impoverished lifestyle (self-neglect or social isolation).
• If there is a comorbidity or other complicating factors, such as depression or substance misuse
• If there are risk factors, for example risk of self-neglect, vulnerability, suicide or risks to others. These could be historical or current risks
• For regular review of a patient's mental state.
Most referrals should be made to the local community mental health team, although early intervention, crisis and home treatment services could also be involved, depending on local availability.
What evidence-based treatment options are available?
Antipsychotics are effective in treating schizophrenia and 70% of patients respond with either complete or partial remission.8
Patients should remain on antipsychotics for one to two years after an episode.2 Withdrawal should be gradual and monitoring should continue for two years after the last acute episode.
Patients who have multiple relapses will require treatment for life. To foster engagement and adherence to treatment, the future is considered in five-year periods.
Medication should be given at the lowest effective dose and monotherapy is advised.
When prescribing, it is important to check if the patient has made an advance statement. This is a plan, written by the patient when they are well, which describes how they would like to be treated when they become ill in the future. It is expected that medical practitioners should consult advance statements when considering treatment options, although they are not legally binding.
Cognitive behaviour therapy (CBT) CBT has been shown to be effective for those with persisting psychotic symptoms or poor treatment adherence and for development
of insight. The broad aims of treatment are to reduce distress, emotional disturbance and disability. The patient is helped to arrive at an understanding of their psychosis to promote active participation and reduce relapse.9
Family therapy is a structured psychoeducational programme. It is useful when there is close contact with family members and patients have either relapsed, are at risk of relapse or have persisting symptoms.
What are the benefits and side-effects of the recommended drug treatments?
All medications have equal efficacy (except for clozapine, which is more effective). Treatment will be determined by the patient's attitude to medication, their presentation and the comparative adverse effect profiles of the drugs.
NICE recommends that the newer atypical antipsychotics are considered as first-line treatment for patients with schizophrenia. This is because of their reduced risk of causing movement disorders such as tardive dyskinesia.
Medication can be given in various forms, including syrups and easily soluble preparations. Patient education, warning about and monitoring for side-effects, simple prescribing regimens and compliance aids are helpful for improving adherence. Forgetfulness, poor treatment adherence or a history of at-risk behaviour when unwell are indications for using depot preparations. Relapse is usually associated with discontinuation of medication.10 The side-effects of atypical antipsychotics are listed in table 2, attached.
How should patients on long-term therapy be monitored?
People with schizophrenia suffer from poor health. A diagnosis of schizophrenia shortens a person's life expectancy by 10 years.11 Not only is there a 10% increased risk of suicide,12 but there is also an increase in mortality from natural causes.
There are a number of factors. Patients with schizophrenia tend to smoke, have a poor diet, exercise less and live in impoverished circumstances. Some may have persisting psychotic symptoms, may not be aware of becoming physically unwell or be poorly motivated to look after themselves. They may find it difficult to seek help because of suspiciousness or apathy and may be suffering from side-effects of their medication (especially weight gain).
There is some evidence that schizophrenia is associated with insulin resistance.13
Patients should be monitored regularly (see table 3, attached).14
Should GPs initiate or change treatment?
Changes in treatment should be done in consultation with secondary care, especially for patients with complex needs.
Switching medication may be appropriate when there are intolerable side-effects, resistance to treatment, physical complications, poor adherence to treatment or the patient requests their medication to be changed. There is no need for a washout period but a brief period of overlap may be important to prevent relapse.Table 1: Possible symptoms of schizophrenia Table 2: Possible side-effects of atypical antipsychotics Table 3: Recommended monitoring for patients with schizophrenia Useful information
The Royal College of Psychiatrists provides information for patients and papers for healthcare professionals
The Scottish Recovery Network includes information on how to promote and support recovery from mental health problems
Rethink is a charity providing information and support for patients with a mental illness and their relatives
The National Schizophrenia Fellowship (Scotland) provides support for patients and carers in Scotland
The National Institute for Health and Clinical Excellence and the Scottish Intercollegiate Guidelines Network have both produced guidelines on the management of schizophrenia.
Dr Deborah Mountain
consultant psychiatrist, Rehabilitation Department, Royal Edinburgh Hospital