Evidence-Based Reviews

Residual symptoms of schizophrenia: What are realistic treatment goals?

Current Psychiatry. 2017 March;16(3):34-40

References

1. Kaiser S, Lyne J, Agartz I, et al. Individual negative symptoms and domains - relevance for assessment, pathomechanisms and treatment [published online July 21, 2016]. Schizophr Res. doi:10.1016/j.schres.2016.07.013.
2. Taylor M, Chaudhry I, Cross M, et al. Towards consensus in the long-term management of relapse prevention in schizophrenia. Hum Psychopharmacol. 2005;20(3):175-181.
3. Schennach R, Riedel M, Obermeier M, et al. What are residual symptoms in schizophrenia spectrum disorder? Clinical description and 1-year persistence within a naturalistic trial. Eur Arch Psychiatry Clin Neurosci. 2015;265(2):107-116.
4. Caligiuri MP, Jeste DV, Lacro JP. Antipsychotic-induced movement disorders in the elderly: epidemiology and treatment recommendations. Drugs Aging. 2000;17(5):363-384.
5. Dolder CR, Jeste DV. Incidence of tardive dyskinesia with typical versus atypical antipsychotics in very high risk patients. Biol Psychiatry. 2003;53(12):1142-1145.
6. Sable JA, Jeste DV. Antipsychotic treatment for late-life schizophrenia. Curr Psychiatry Rep. 2002;4(4):299-306.
7. Newcomer JW. Second-generation (atypical) antipsychotics and metabolic effects: a comprehensive literature review. CNS Drugs. 2005;19(suppl 1):1-93.
8. Khan AY, Redden W, Ovais M, et al. Current concepts in the diagnosis and treatment of schizophrenia in later life. Current Geriatric Reports. 2015;4(4):290-300.
9. Alexopoulos GS, Streim J, Carpenter D, et al; Expert Consensus Panel for Using Antipsychotic Drugs in Older Patients. Using antipsychotic agents in older patients. J Clin Psychiatry. 2004;65(suppl 2):5-99; discussion 100-102; quiz 103-104.
10. Robinson D, Woerner MG, Alvir JM, et al. Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder. Arch Gen Psychiatry. 1999;56(3):241-247.
11. Freitas C, Fregni F, Pascual-Leone A. Meta-analysis of the effects of repetitive transcranial magnetic stimulation (rTMS) on negative and positive symptoms in schizophrenia. Schizophr Res. 2009;108(1-3):11-24.
12. Rector NA, Beck AT. Cognitive behavioral therapy for schizophrenia: an empirical review. J Nerv Ment Dis. 2012;200(10):832-839.
13. Stobbe J, Mulder NC, Roosenschoon BJ, et al. Assertive community treatment for elderly people with severe mental illness. BMC Psychiatry. 2010;10:84.
14. Hennekens CH, Hennekens AR, Hollar D, et al. Schizophrenia and increased risks of cardiovascular disease. Am Heart J. 2005;150(6):1115-1121.
15. Bushe CJ, Taylor M, Haukka J. Mortality in schizophrenia: a measurable clinical point. J Psychopharmacol. 2010;24(suppl 4):17-25.
16. Nasrallah HA, Meyer JM, Goff DC, et al. Low rates of treatment for hypertension, dyslipidemia, and diabetes in schizophrenia: data from the CATIE schizophrenia trial sample at baseline. Schizophr Res. 2006;86(1-3):15-22.
17. Nasrallah HA, Targum SD, Tandon R, et al. Defining and measuring clinical effectiveness in the treatment of schizophrenia. Psychiatr Serv. 2005;56(3):273-282.
18. Overall JE, Gorham DR. The Brief Psychiatric Rating Scale (BPRS): recent developments in ascertainment and scaling. Psychopharmacol Bull. 1988;24:97-99.
19. Kay SR, Fiszbein A, Opler LA. The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophr Bull. 1987;13(2):261-276.
20. Addington D, Addington J, Schissel B. A depression rating scale for schizophrenics. Schizophr Res. 1990;3(4):247-251.
21. Guy W. ECDEU Assessment manual for psychopharmacology revised, 1976. Rockville, MD: US Department of Health, Education, and Welfare; Public Health Service; Alcohol, Drug Abuse, and Mental Health Administration; National Institute of Mental Health Psychopharmacology Research Branch, Division of Extramural Research Programs; 1976.
22. Barnes TR. A rating scale for drug-induced akathisia. Br J Psychiatry. 1989;154:672-676.
23. Simpson GM, Angus JWS. A rating scale for extrapyramidal side effects. Acta Psychiatr Scand. 1970;45(212):11-19.
24. Dott SG, Weiden P, Hopwood P, et al. An innovative approach to clinical communication in schizophrenia: the Approaches to Schizophrenia Communication checklists. CNS Spectr. 2001;6(4):333-338.
25. Dott SG, Knesevich J, Miller A, et al. Using the ASC program: a training guide. J Psychiatr Pract. 2001;7(1):64-68.
26. Barker S, Barron N, McFarland BH, et al. Multnomah Community Ability Scale: user’s manual. Portland, OR: Western Mental Health Research Center, Oregon Health Sciences University; 1994.
27. Lehman AF. A quality of life interview for the chronically mentally ill. Eval Program Plann. 1988;11(1):51-62.
28. Heinrichs DW, Hanlon TE, Carpenter WT Jr. The Quality of Life Scale: an instrument for rating the schizophrenic deficit syndrome. Schizophr Bull. 1984;10(3):388-398.
29. Becker M, Diamond R, Sainfort F. A new patient focused index for measuring quality of life in persons with severe and persistent mental illness. Qual Life Res. 1993;2(4):239-251.
30. Liberman RP, Kopelowicz A, Ventura J, et al. Operational criteria and factors related to recovery from schizophrenia. Int Rev Psychiatry. 2009;14(4):256-272.

What are realistic treatment goals to manage residual symptoms in schizophrenia?

We believe that because remission in schizophrenia has been defined consensually, the bar for treatment expectations is set higher than it was 20 years ago. There can be patient-, family-, and system-related variables affecting the feasibility of treating residual symptoms. Providers who treat patients with schizophrenia should consider the following treatment goals:

Prevent relapse and acute psychiatric hospitalization
Use evidence-based strategies to minimize or monitor adverse effects
Monitor compliance and consider use of depot antipsychotics combined with patients’ preference
Facilitate ongoing safety assessment, including suicide risk
Monitor negative and cognitive symptoms in addition to positive symptoms, using evidence-based management
Encourage collaboration of care with family, caretakers, and other members of the treatment team
Empower patients by providing psychoeducation and social skills training and assisting in their vocational rehabilitation
Educate the patient and family about healthy lifestyle interventions and medical comorbidities common with schizophrenia
Perform baseline screening and follow-up for early detection and treatment of medical comorbidities in patients with schizophrenia
Improve functional status and quality of life.

In addition to meeting these treatment goals, a measurement-based method can be implemented to monitor improvement and status of the independent treatment domains. A collection of rating instruments can be found in Table 2.^17-30

Summing up

The clinical presentation of patients with residual symptoms of schizophrenia differs from that of other patients with schizophrenia. Our understanding of residual symptoms in schizophrenia has come a long way in the last decade; however, we are still far from pinning the complex nature of these symptoms, let alone their management. Given the risk of morbidity and disability, there clearly is a need for further investigation and investment of time and resources to support developing novel pharmacological treatment options to manage residual symptoms in patients with schizophrenia.

Because patients with residual symptoms of schizophrenia usually are older, psychiatrists should be responsible for implementing necessary screening assessments and should closely collaborate with primary care practitioners and other specialists, and when necessary, treat comorbid medical conditions. The importance of educating patients, their families, and the treatment team cannot be overlooked. Further, psychiatric treatment facilities should offer and promote healthy lifestyle interventions.

Bottom Line

Patients with remitted schizophrenia could continue to have negative symptoms, such as social withdrawal or low energy or could hold onto strange beliefs. Often, patients with residual symptoms of schizophrenia are older and could be more susceptible to adverse effects of psychotropics. Include psychosocial interventions in your treatment plan, evaluate for comorbid medical conditions, and monitor patients for improvement or relapse.

Related Resources

Fenton WS, Dickerson F, Boronow J, et al. A placebo-controlled trial of omega-3 fatty acid (ethyl eicosapentaenoic acid) supplementation for residual symptoms and cognitive impairment in schizophrenia. Am J Psychiatry. 2001;158(12):2071-2074.
Sensky T, Turkington D, Kingdon D, et al. A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Arch Gen Psychiatry. 2000;57(2):165-172.
Buchanan RW. Persistent negative symptoms in schizophrenia: an overview. Schizophr Bull. 2007;33(4):1013-1022.

Drug Brand Names

Aripiprazole • Abilify
Asenapine • Saphris
Bupropion • Wellbutrin
Clozapine • Clozaril
Fluoxetine • Prozac
Fluvoxamine • Luvox
Iloperidone • Fanapt
Lurasidone • Latuda
Olanzapine • Zyprexa
Paroxetine • Paxil
Quetiapine • Seroquel
Risperidone • Risperdal
Venlafaxine • Effexor
Ziprasidone • Geodon

Residual symptoms of schizophrenia: What are realistic treatment goals?

References

What are realistic treatment goals to manage residual symptoms in schizophrenia?

Summing up

Bottom Line

Pages

Recommended Reading