Current Challenges in the Treatment of Schizophrenia

Challenges surrounding the treatment of patients with schizophrenia and their overall impact on patient care and rates of relapse.

John M. Kane, MD: Hi, and thank you for joining this Peer Exchange titled “Expert Perspectives on Schizophrenia Treatment Approaches and Relapse Prevention.” Schizophrenia is a complex, long-term medical illness affecting about 1% of Americans, which interferes with a person’s ability to think clearly, make decisions, and relate to others. There are many unmet needs, and a large number of patients don’t adequately respond to treatment or have difficulty adhering to prescribed medications. Many relapses and hospitalizations could be avoided if their medications were stabilized.

In this Peer Exchange panel discussion, I’m joined by 2 of my colleagues who are experts in managing schizophrenia. We will review unmet needs, patient adherence, and treatment with long-acting injectable antipsychotics. Emerging agents and novel management approaches will also be discussed.

I’m Dr. John Kane, professor and chairman of psychiatry at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York.

Participating today on our distinguished panel are: Dr. Jeffrey Lieberman, Lawrence C. Kolb professor and chairman of the Department of Psychiatry at Columbia University College of Physicians and Surgeons, and psychiatrist-in-chief at the Columbia University Medical Center of the NewYork-Presbyterian Hospital in New York, New York; and T. Scott Stroup, professor of psychiatry at Columbia University College of Physicians and Surgeons in New York, New York.

Thank you so much for joining us. Let’s begin.

I’d like to start off by addressing the question of: What are the unmet needs in the treatment of schizophrenia? I think there are several. First, we know that our medications are not consistently efficacious against all of the signs and symptoms of this illness. We know that some patients continue to struggle with negative symptoms and cognitive dysfunction. We don’t have adequate treatments for those particular problems. The medications that we do have tend to be most efficacious against positive symptoms. But one of the challenges is that patients have difficulty taking these medications on a regular basis over a long period of time. Just as patients with any chronic medical illness, they have challenges with adherence. I think that is one of the big unmet needs, and the consequences of nonadherence, as we’ll discuss more as we go along, are avoidable relapses and rehospitalizations, and the interference that can have in people’s ability to function. And there are other concerns as well.

So we have a number of unmet needs. I think we have to recognize the fact that some of them can be more readily addressed than others. Some of the unmet needs will require further progress in drug development, and some could be partially solved by us doing a better job with the treatments that we have available. Scott, what are your thoughts regarding some of the challenges in treating schizophrenia?

T. Scott Stroup, MD, MPH: I agree with your assessment of the unmet needs. Some other things that I was thinking of include the problem of treatment-resistant schizophrenia. There are a significant number of people who just don’t respond at all to the existing antipsychotic medications, or standard antipsychotic medications. There’s 1 that both of you have studied a lot, clozapine, that is better than the other medications for treatment-resistant schizophrenia, but it’s not often used.

John M. Kane, MD: And people still debate that, right?

T. Scott Stroup, MD, MPH: Right, it’s still debated and it has a lot of adverse effects. It’s hard to use. We could use a better treatment for treatment-resistant schizophrenia, for sure. Another real challenge is a lot of people with schizophrenia have substance-use disorders as well, and that’s a real challenge. When we’ve studied populations that include people who use substances, nothing really works very well. It doesn’t matter what it is. So that’s a challenge. And then probably the most common issue and problem is people not taking their medications. Adherence is a big issue.

John M. Kane, MD: And then we have all of the health risks, too, right? We have a higher prevalence of smoking, and you mentioned substance abuse. All of these are challenges.