/publications/issue/2008/2008-03/2008-03-8440

Adherence Key to Effective Management of Schizophrenia

Author: Yvette C. Terrie, BSPharm, RPh

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

Schizophrenia is a chronic, complex, and challenging disorder that requires long-term treatment, affecting approximately 1% of the world population—an estimated 2.5 million individuals in the United States—and rates of incidence are comparable among both men and women.1-4 In men, the onset of schizophrenia is typically during the teen years or early 20s; and in women,the onset is typically in the 20s or early 30s. Onset in childhood is rare; however, early adolescent or late-life onset (referred to as paraphrenia) may occur.1

Alcohol abuse, drug abuse, social anxiety, and depression are common among patients with schizophrenia, and an estimated 10% of schizophrenic patients commit suicide.4-6 Addiction to nicotine is the most common form of substance abuse in patients with schizophrenia; this population is addicted at 3 times the rate of the general population.4

Schizophrenia may exist alone or in conjunction with other psychiatric or medical conditions. In order to effectively counsel patients affected by schizophrenia, pharmacists should have some insight into this condition and the treatment options available for the management of schizophrenia.

Types of Schizophrenia

Schizophrenia is categorized in the following 5 subtypes:

  1. Paranoid schizophrenia—delusional thoughts or auditory hallucinations, argumentativeness, and anger
  2. Catatonic schizophrenia—stupor, agitation, decreased sensitivity to painful stimulus, and inability to take care of personal needs
  3. Disorganized schizophrenia—incoherence, regressive behavior, flat effect, social withdrawal, and repetitive mannerisms
  4. Undifferentiated schizophrenia—symptoms of >1 type of schizophrenia
  5. Residual schizophrenia—more prominent symptoms, followed by a prolonged period of mild negative symptoms1-4

Causes

According to the American Psychiatric Association (APA), although the exact cause of schizophrenia is unknown, research suggests that biological and environmental factors play a role in both the onset and course of schizophrenia.7 In addition, scientists know that some hereditary basis or genetic predisposition for the disease exists.1,4,6,7 Statistics indicate that, although an estimated 1% of the population has schizophrenia, it is seen in 10% of individuals that have a first-degree relative with schizophrenia.4

Signs and Symptoms

Since no one symptom positively identifies schizophrenia, patients may exhibit various types and degrees of symptoms, which can be classified into 3 general categories: positive symptoms (eg, delusions, hallucinations, unusual perceptions or thoughts), negative symptoms (eg, loss or decrease in ability to initiate plans, speak, or express emotion), and cognitive symptoms (problems with attention, sustaining attention, certain type of memory, and ability to plan and organize things).1,2,4,6,7

Effective Patient Counseling

Because schizophrenia is a long-term and recurrent illness, patient adherence to therapy is essential. At the annual APA meeting in May 2007, results were presented from the National Adherence Initiative in Schizophrenia Survey, which involved 13,000 patients with schizophrenia and used a new screening tool. The survey indicated that the most common reasons for failing to take medication prescribed for schizophrenia by 2 out of 3 patients included poor insight (74%), forgetting to take medication (68%), and previous discontinuation of medication (67%).6 The screening tool identified 8 factors that can be associated with nonadherence: (1) poor insight about illness; (2) forgetting medication; (3) stigma associated with taking medication; (4) presence of psychotic symptoms; (5) previous discontinuation of medication; (6) stigma about hospitalization; (7) drug/alcohol abuse; and (8) experiencing adverse effects from prescribed medication.8

Treatment

Although no cure exists for schizophrenia, a variety of treatment options are available for its management, including pharmacologic therapy, psychotherapy, rehabilitation, and family and community support.1,2,4 The main goals of therapy are the reduction or exacerbation of symptoms and to minimize the incidence of relapse.5 An early diagnosis and initiation of a treatment plan are very important and may prevent or delay the severity of this condition or the need to consider augmentation therapy.5,9

The 2 general classes of drugs available for treating this condition are conventional antipsychotics (eg, chlorpromazine [Thorzine], thioridazine [Mellaril], and haloperidol [Haldol]) and atypical antipsychotics (eg, clozapine [Clozaril], risperidone [Risperdal], olanzapine [Zyprexa], quetiapine [Seroquel], ziprasidone [Geodon], and aripiprazole [Abilify]), which are available in a variety of dosage forms, such as tablets, oral-disintegrating tablets, liquids, and short- and long-acting intramuscular injections. Switching to the use of injectable long-acting antipsychotics via intramuscular administration for certain patients (ie, patients with indifference or denial of illness who cannot reliably take daily oral medications) may be necessary and also may produce better results in efficacy, tolerability, and relapse prevention.1,5

Conventional antipsychotics can control positive symptoms such as delusions and hallucinations. Adverse effects associated with the use of conventional antipsychotics include sedation, dystonia, tremors, elevated prolactin levels, and weight gain. These agents also may cause akathisia (motor restlessness), which may result in patient nonadherence, as well as tardive dyskinesia.1

Atypical antipsychotics were first introduced in the 1990s and are used to manage both positive and negative symptoms associated with schizophrenia. These agents are less likely to cause extrapyramidal effects, may have a lower incidence of tardive dyskinesia, and produce little or no elevation of prolactin levels. 1 According to a joint panel of the American Diabetes Association, the APA, the American Association of Clinical Endocrinologists, and the North American Association for the Study of Obesity, the use of atypical antipsychotics is associated with incidence of weight gain.10 Studies also show an association between atypical antipsychotic use and the development of prediabetes, diabetes, and elevated blood lipid levels.10

The panel recommends baseline screening of personal and family history of obesity, diabetes, and dyslipidemia, fasting glucose, and fasting lipid profile prior to initiating therapy and routine monitoring while on therapy.5,10 It also concluded that the atypical antipsychotics differ in their risk profiles and that some agents, although effective treatment options, raise a greater risk of weight gain, diabetes, and lipid disorders than other agents.10

Clozapine and olanzapine produce the greatest weight gain; quetiapine and risperidone produce intermediate weight gain; ziprasidone and aripiprazole produce the least weight gain.10,11 Results from a study published in the January 9, 2008, issue of the Journal of the American Medical Association report that metformin and lifestyle interventions, alone or in combination, were effective for antipsychotic-induced weight gain and abnormalities in insulin sensitivity.11,12

Although the FDA had not previously approved any medication to treat schizophrenia in adolescents, the FDA approved risperidone in August 2007 and approved aripiprazole in November 2007 for the treatment of schizophrenia in adolescents aged 13 to 17.13,14 Also in November 2007, quetiapine extended-release tablets received an expanded indication and were FDA approved for maintenance treatment of schizophrenia in adults.15

The Pharmacist's Role

As one of the most accessible health care professionals, pharmacists can positively impact patient outcomes by stressing the importance of medication adherence, as well as encouraging patients to maintain routine visits with their primary health care provider. When counseling patients, pharmacists should remind them about the benefits of medication therapy and educate them of the potential adverse effects of the selected medication.

For more information on schizophrenia, please visit the following Web sites:

National Alliance on Mental Illness:
www.nami.org

National Institute of Mental Health,
National Institutes of Health:
www.nimh.nih.gov

Mental Health America (formerly
known as the National Mental
Health Association):
www.nmha.org

Patients should be reminded to not discontinue any of their medication unless directed by their physician, report any side effects to their primary health care provider, and to not use any other medications, including nonprescription drugs, vitamins, and herbal medications, without seeking advice from their primary health care provider. It also is important for patients to be advised against the use of alcohol. Because quitting smoking may be difficult for patients with schizophrenia, smoking cessation strategies such as nicotine replacement methods may be recommended. If patients do not stop smoking or start smoking, physicians should monitor their response to antipsychotic therapy.4

Successful therapy starts when patients have a thorough understanding of their therapy and the importance of therapy adherence. Pharmacists can be instrumental in identifying possible contraindications or drug interactions for this patient population and recommending various strategies that patients can use to increase adherence to their therapy, such as the use of medication reminder devices, using automated-refill features to ensure prescriptions are filled on time, and using 1 pharmacy for all prescriptions. Most importantly, pharmacists can assist patients with schizophrenia by showing empathy, providing encouragement and support, and reminding them that adhering to their therapy is the most effective tool in managing schizophrenia.

References

  1. Beers M, Porter RS, Jones TV, et al. Psychiatric disorders. In: The Merck Manual of Diagnosis and Therapy. 18th ed. Whitehouse Station, NJ: Merck Research Laboratories. 2006:1722-1732.
  2. Schizophrenia: What You Need to Know. Mental Health of America Web site. www.mentalhealthamerica.net. Accessed January 2, 2008.
  3. Understanding Schizophrenia and Recovery. National Alliance on Mental Illness Web site. www.nami.org. Accessed January 2, 2008.
  4. Schizophrenia. National Institute of Mental Health Web site. www.nimh.nih.gov. Accessed January 4, 2008.
  5. Mahgerefteh S, Pierre JM, Wirshing DA, et al. Treatment challenges in schizophrenia: a multifaceted approach to relapse prevention. Psychiatr Times. 2006;23(4). www.psychiatrictimes.com.
  6. Schizophrenia. Medline Plus Web site. www.nlm.nih.gov. Accessed January 6, 2008.
  7. Let's Talk Facts About Schizophrenia. American Psychiatric Association Web site. healthyminds.org. Accessed January 13, 2008.
  8. New screening tool can help identify patients who fail to take their medication as prescribed [press release]. Titusville, NJ: Janssen LP; May 22, 2007. Janssen Pharmaceutical Web site. www.janssen.com. Accessed January 10, 2008.
  9. Davis J. The Choice of Drugs for Schizophrenia. New Engl J Med. February 2, 2006;354(5):518-520. content.nejm.org. Accessed January 10, 2008.
  10. Antipsychotic Drugs Raise Obesity, Diabetes and Heart Disease Risk. American Diabetes Association Web site. www.diabetes.org. Accessed January 10, 2008.
  11. Lie D. Metformin and lifestyle changes effective in antipsychotic-induced weight gain. Medscape Web site. www.medscape.com. Accessed January 11, 2008.
  12. Wu RR, Zhao JP, Jin H, Shao P, Fang MS, Guo XF, et al. Lifestyle intervention and metformin for treatment of antipsychotic-induced weight gain. JAMA. 2008;299(2):185-193.
  13. FDA Approves Risperdal for Two Psychiatric Conditions in Children and Adolescents. FDA Web site. www.fda.gov. Accessed January 10, 2008.
  14. U.S. Food and Drug Administration approves ABILIFY (aripiprazole) for adolescent patients with schizophrenia [press release]. Tokyo, Japan, and Princeton, NJ: Otsuka Pharmaceutical Co Ltd and Bristol-Myers Squibb Co; November 6, 2007. newsroom.bms.com.
  15. Seroquel XR Receives Approval From FDA For Maintenance Treatment Of Schizophrenia. Medical News Today Web site. www.medicalnewstoday.com. Accessed January 10, 2008.