Schizophrenia: Chronic Disease Management
PracticeUpdate: Are there symptoms in patients with chronic disease that might warrant an escalation of care?
Dr. Oliphant: In individuals with chronic disease, symptom escalation or exacerbation that might warrant a referral to psychiatry from primary care would be the development of symptoms that were not there previously. Some patients will have residual psychosis. They have schizophrenia. They are maybe on a medication that’s been stable for years. We look at long-acting injectables or medications that a patient doesn’t have to take by mouth every day. They’re already on these medications, and they have this underlying maybe paranoia or hallucinations that are not bothersome for the patient. So, they will say, "Yes, I hear music.” Or, "Yes, I still hear this person’s voice, but I can ignore it." If the symptoms come to a point where the patient can no longer ignore what is being said, they are given directives by the hallucinations to perform certain actions that could harm themselves or others, there would be a need escalation. These are, "I've been told not to bathe. I’ve been told not to eat. I’ve been told that this person is following me." And the patient begins to act in a way that they need self-defense. They’re telling you they’re buying weapons, or they’re starting to have stakeouts in their home to make sure no one is coming near them.
If there’s an increase or change in the person’s baseline symptoms, that is definitely a time to enlist the help of a psychiatrist. Another aspect you would want to consider is if the person develops side effects from the medication. The first thought is, "Okay, this medicine is causing parkinsonism. It looks like the person’s getting a pill rolling tremor or shuffling gait. So, we need to stop the medication." Abruptly stopping the medication can actually make those side effects a little worse, but also abruptly stopping can exacerbate the psychosis or the acute decompensation of symptoms. So, that would be another time to enlist the help of a psychiatrist of, "How do we transition medications? Or what are treatments available to decrease these side effects the patient is experiencing?" Because maybe the patient really likes the medicine. They don’t want to change, but the side effects are becoming disruptive to their day-to-day life. Those are sometimes, in an individual with chronic schizophrenia, that a primary care provider may seek the help or consult of a psychiatrist.
PracticeUpdate: Are there any long-term drug monitoring considerations that primary care providers should be aware of for patients being treated for schizophrenia?
Dr. Oliphant: Long-term surveillance for patients with schizophrenia that primary care should be aware of would include, one, there’s a scale called the AIMS scale or Abnormal Movement Inventory Scale. It can be done very quickly in the office, takes less than five minutes, but it is a rating scale that assesses movement disorders that can be a result of antipsychotic medications. Again, antipsychotics, the first-generations are all focused on dopamine blockade. Second-generation, we are looking at dopamine blockade as well as some serotonin receptors. When we look at where the dopamine receptors are in the brain, one of the main pathways is the nigrostriatal pathway. Blocking dopamine here can cause a pseudo-parkinsonism. And we have our extrapyramidal symptoms where people may have some muscle spasms or abnormal movements of their mouth, or involuntary movements of their trunk or their hands. There are some medications now available for treatment of tardive dyskinesia, but the goal would be to intervene before we get to the tardive dyskinesia phase because, at this phase, the movement disorders are not always reversible. Even with treatment management, the movement disorder does not go away completely.
The Abnormal Movement Inventory Scale or AIMS scale should be done prior to the initiation of an antipsychotic and at least every six months while the person is on maintenance therapy just to, again, monitor for movement or abnormal movements because, sometimes, the patients don’t even notice it. It’s mild and subtle to them. It’s involuntary. Others looking at them may see it, but the patient, themselves, may not. That is one monitoring scale that should be followed and can be done in a primary care clinic. Another would be thinking more towards our second-generation antipsychotics. Insulin resistance can cause metabolic syndrome. So, every at least once a year, hemoglobin A1C, lipid panels should be monitored. Sooner or more closely together is also appropriate. But a rise in an A1C in a person not previously diabetic, lipid panels, LDL cholesterol going up is something to consider, also weight gain as a result of the insulin resistance. So, definitely monitoring weight.
If a person is noted to have significant weight gain, more than, say, 5% body weight within a three-to six-month period, there should be a discussion of lifestyle, diet, but also, "Is there a need to change the medication?" Because some of the second-generation antipsychotics are worse than others. Quetiapine, olanzapine, and clozapine are three of the, I would say, worst offenders when it comes to significant weight gain, development of diabetes or metabolic syndrome. Any of them can cause it, but olanzapine, quetiapine, and clozapine are the ones that we see the highest amount of weight gain and development of diabetes in patients with schizophrenia in long-term treatment.
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