LAS VEGAS – Calibration of treatment response is a major challenge in patients with schizophrenia, according to Dr. Peter J. Weiden.
“On some level all of our patients with schizophrenia are both responders and nonresponders to medication at the same time,” Dr. Weiden said at the annual psychopharmacology update held by the Nevada Psychiatric Association. “What I mean is that the vast majority of patients with schizophrenia have fewer symptoms on antipsychotic medication, but very few patients on medicine will be perfectly OK without any symptoms or problems.”
Dr. Peter J. Weiden
Dr. Weiden, professor of psychiatry at the University of Illinois at Chicago, went on to note that clinicians tend to calibrate medication response as the improvement in psychotic symptoms or stability, compared with how the person would be without medication. But the patient will not see it that way. Instead, the patient will calibrate how he is doing with medication, compared with how he felt before the illness started – or how he is compared with others without a diagnosis of schizophrenia.
“We still don’t cure schizophrenia; patients want to be normal,” he said. “We don’t make them normal with our medications, and medications don’t always work as expected. At the very least, when we talk about response and nonresponse, we need to be respectful of the patient’s point of view.”
The same calibration dilemma happens with the side effect burden from antipsychotics. While the side effect burden from current antipsychotics is much better than it used to be in the preclozapine era, patients are still likely to have to put up with a variety of bothersome side effects. Telling the patient: “You should be grateful, because it used to be a lot worse!” somehow doesn’t come across as helpful.
Factors affecting calibration of treatment include the acuity of the patient’s illness, duration of illness, relative engagement in the treatment process (meaning “our outcomes should be a lot better for patients who are engaged in our treatment, who come to treatment, than those who don’t,” he said), comorbidities that may limit efficacy, the clinician’s philosophy of treatment, and the patient’s access to “best practices” care.
Although all antipsychotics can be used for all phases of schizophrenia, Dr. Weiden cautioned that individual antipsychotics are not interchangeable. “There’s always some efficacy risk when changing from an antipsychotic known to be effective for an individual patient,” he said. “Control of psychotic symptoms is always important. If you work in an inpatient unit, there’s a lot of stress and a lot of drive toward rapid resolution of symptoms in a way that’s easy and a way that’s safe.”
Desirable characteristics of pharmacologic agents for immediate initiation of acute treatment, he continued, include rapid onset of action, low toxicity, availability in multiple routes of administration, ease of use, low potential for drug-drug interactions, and ease of crossover to an oral antipsychotic agent. However, managing the acute psychosis in an ER or hospital setting “isn’t all about the medication,” he said.
“It’s very traumatic to be held down. It’s humiliating. It’s disruptive. Yes, we need to hospitalize people when they’re unsafe, but a lot of nonpharmacologic things we do are very important and will reduce the risk of complications from medication.” These include reassuring the patient, making him or her physically comfortable, reducing triggers that may escalate the situation, contacting the family, and educating the staff about the treatment plan.
In his clinical opinion, the inpatient use of a haloperidol p.r.n. regimen often is unsound and unsafe. “Very often on an inpatient unit, the haloperidol p.r.n. orders are done separately from the standing orders,” Dr. Weiden explained. “So you’ll have a clinician do a careful evaluation and write the standing orders of the medication, but the p.r.n.s are kind of boilerplate, and they get Haldol. The brain cannot ‘tell’ the difference between a standing order and a p.r.n. order of haloperidol. It is dangerous; patients die from this. It’s not common to have a life-threatening reaction to p.r.n. haloperidol, but it’s not rare, either, and the automatic use of haloperidol p.r.n. certainly no longer meets any reasonable standard of safety.”
The same antipsychotic medication can be used acutely and in maintenance, Dr. Weiden said, but if the patient relapses, you might consider changing to another agent. “If you know the patient well, and you know that the last medicine helped keep the patient stable but they still have lots of symptoms and a pretty crummy life, you might want to consider that as an opportunity to change the medicine,” he said. ‘However, if the patient came in because they went out drinking with their buddies and they got intoxicated, you really should not change the medicine, because in this situation, it was not a pharmacologic failure of the medication regimen,” Dr. Weiden said. To change or not to change medication “is a really big issue for someone’s life trajectory.”