REPORTING FROM THE COLLEGE 2018
TAMPA (FRONTLINE MEDICAL NEWS) – The secret to optimal long-term disease control in schizophrenia is to implement the same type of continuous and close management provided to other chronic diseases, like hypertension or inflammatory bowel disease, according to a lecture delivered at the annual meeting of the American College of Psychiatrists.
In the Dean Award Lecture – a talk characterized as “a stroll through the long-term understanding of the treatment of schizophrenia” – Ira D. Glick, MD, said that, although antipsychotics provide the foundation of disease control, patients and families need to understand and respect disease chronicity.
Dr. Glick remembered speculation in his training that bad parenting might be a cause or contributor to the development of schizophrenia. Now, genetic susceptibility is recognized as a dominant factor for both developing the disease and determining severity, said Dr. Glick , professor emeritus in the department of psychiatry and behavioral sciences at Stanford (Calif.) University. Regardless of etiology, however, he believes that convincing patients and families that schizophrenia is a lifetime disease is a critical first step to treatment compliance that optimizes adequate symptom control.
“In the last 5 or 6 years, I did something that no one has ever done before. I looked at the outcomes of patients treated for decades,” Dr. Glick recounted. Specifically, he contacted patients who had been in his care for up to 50 years. In “this naturalistic study,” he specifically asked the patients to rate their adherence to antipsychotics and to provide a global assessment of their life satisfaction, both on a scale of 1-10.
“What I found in a relatively large sample was that the more adherent patients were to their medication, the more likely they were to report adequate satisfaction with their life,” Dr. Glick said. For those who were not adherent, life in general “has been a disaster.”
This finding is not entirely surprising given the power of antipsychotics to change thinking. However, for those engaged in the immediate task of controlling acute symptoms, the importance of chronicity might not be given adequate emphasis. This requires educating patients and their families about the need to embark on lifetime treatment, Dr. Glick said. Like a diagnosis of diabetes, a diagnosis of schizophrenia means constant vigilance for manifestations of disease and appropriate adjustments of therapy to improve long-term outcomes.
Since evaluating the relationship between medication adherence and long-term outcomes in patients with schizophrenia treated at Stanford, the same type of evaluation was conducted with population samples from the Veterans Affairs system and from China. The data “show exactly the same thing,” Dr. Glick said.
It is important to use every available resource in helping patients recognize and deal with schizophrenia chronicity. In addition to engaging families, he believes that organizations such as the National Alliance on Mental Illness or NAMI , are useful sources of support.
Earlier in his career, Dr. Glick participated in a randomized clinical trial of hospitalization for patients with schizophrenia. Recounting that experience, he reported that he was struck by the improvement in outcomes among patients who grasped that schizophrenia must be approached as a chronic disease.
“Once the patient understood what they had, they were much more apt to be adherent and to stay on their medication for their lifetime,” Dr. Glick reported. Although there is evidence that identifying an effective antipsychotic is key to disease control, “you have to talk to the patient, not just throw a medicine at them,” he said. This makes educating patients and families the key step in embarking on indefinite, close disease monitoring.
Control of schizophrenia over time is likely to vary as symptoms wax and wane, but this is true of other chronic disease processes. Diabetes, for example, requires frequent monitoring for and adjustment of blood glucose. Often medications for diabetes must be intensified or switched. The monitoring and management of schizophrenia is analogous.
One strategy for improving control of schizophrenia is to educate patients about this concept. Approaching schizophrenia as a chronic illness like other diseases that require lifetime drugs will help reduce the crises and the adverse effects associated with nonadherence to tight management, Dr. Glick maintained.
Dr. Glick reported financial relationships with Forum Pharmaceuticals, Johnson & Johnson, Neurocrine, Sunovion, and Teva.