practical strategies for the treatment of patients with schizophrenia leslie citrome, md, mph...

Practical Strategies for the Treatment of Patients

with Schizophrenia

Leslie Citrome, MD, MPHAdjunct Professor of Psychiatry & Behavioral Sciences,

New York Medical College, Valhalla, NY

Sponsored by The France Foundation.Supported by an educational grant from Sunovion.

It is the policy of The France Foundation to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All faculty, activity planners, content reviewers, and staff participating in this activity will disclose to the participants any significant financial interest or other relationship with manufacturer(s) of any commercial product(s)/device(s) and/or provider(s) of commercial services included in this educational activity.

The intent of this disclosure is not to prevent a person with a relevant financial or other relationship from participating in the activity, but rather to provide participants with information on which they can base their own judgments. The France Foundation has identified and resolved any and all conflicts of interest prior to the release of this activity.

Faculty Disclosure

DisclosureLeslie Citrome, MD, MPH

Leslie Citrome, is a consultant for, has received honoraria from, or has conducted clinical research supported by the following:

Abbott, AstraZeneca*, Avanir, Azur, Barr, Bristol-Myers Squibb*, Eli Lilly*, Forest, GlaxoSmithKline, Janssen*, Jazz, Merck*, Novartis*, Noven*, Pfizer*, Shire*, Sunovion*, Valeant*, and Vanda.

* Denotes a relationship in effect anytime during the past 12 months

Learning Objectives• Recognize criteria for remission and recovery in

patients with schizophrenia. Evaluate patients for the potential to achieve these outcomes and implement strategies directed towards these goals

• Recognize how clinical practice guidelines relate to the individualized treatment of patients with schizophrenia

• Integrate strategies that will help to improve the effective use of medications by patients with schizophrenia

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Schizophrenia – A Set of Symptoms

Blunted affectEmotional withdrawalActive social avoidance

Lack of spontaneityPoor rapport

Suspiciousness/paranoiaGrandiosity/DelusionsUnusual thought content

Poor attentionConceptual disorganization

Difficulty in abstract thinkingDisorientation

Positive Symptoms

Negative Symptoms “Disorganized” Symptoms

Clinical and Pathophysiological Course of Schizophrenia

Lieberman JA, et al. Biol Psychiatry. 2001;50(11):884-897.

What is Response?

• Speed?• Magnitude?• Proportion responding?• Effect in refractory patients?

Measuring Efficacy - Decrease in PANSS

Lieberman JA, et al. N Engl J Med. 2005;353(12):1209-1223.

Decrease in PANSS Factors

Heresco-Levy U, et al. Biological Psychiatry. 2004;55:165-171.

Arbitrary Categorical Changes in PANSS

Response defined as at least a 30% decrease from the baseline PANSS to the last observation

Daniel DG, et al. Neuropsychopharmacology.1999;20:491-505.

Functionality

Distribution of patients achieving ≥ 1 change in Personal and Social Performance (PSP) Scale category at end point. Intent-to-treat population; PSP scale scores at end point for individual patients to show a clinically relevant change in personal and social functioning as represented by improvement of ≥ 1 category (classified as one 10-point interval); PSP = Personal and Social Performance Scale.

Kane J, et al. Schizophr Res. 2007;90:147-161.

What is remission and recovery in

patients with schizophrenia?

Response vs Remission

Disease Response Remission

Depression 50% ↓ HAM-D HAM-D ≤ 7

Mania 50% ↓ YMRS YMRS ≤ 12

Schizophrenia 20-30% ↓ PANSS ?

Andreasen N, et al. Am J Psychiatry. 2005;162:441-449.

Remission Definitions


Proposed Criteria for Remission


RecoveryDavidson’s Nine

Common Elements of Recovery1. Renewing hope and commitment

2. Redefining self

3. Incorporating illness into life as a whole

4. Involvement in meaningful activities

5. Overcoming stigma

6. Assuming control

7. Becoming empowered and exercising

citizenship

8. Managing symptoms

9. Finding social support

Peebles S, et al. Psych Clin N Am. 2007;30:567-583.

SAMHSA ‘‘Fundamental Components of Recovery’’

1.Consumer self-direction2.Individualized and person-centered treatment3.Empowerment4.A holistic treatment focus5.A nonlinear perspective of change6.Treatment focused on strengths instead of deficits7.The inclusion of peer support in treatment8.Respect for consumers and consumer self-respect9.Consumer acceptance of personal responsibility10.Hope in recovery

Treatment Effectiveness

EfficacyDoes Rx reduce Sx?

Tolerability and Safety

Does Rx cause SE?

Adherence/PersistenceWill Pt take Rx?

TreatmentEffectiveness

Combines all measures

Lehman AF, et al. Am J Psychiatry. 2004;161(2 suppl):1-56.Swartz MS, et al. Schizophr Bull. 2003;29(1):33-43.


CATIE Primary Outcome Measure:All-Cause Treatment Discontinuation

All-Cause Discontinuation

Efficacy Tolerability

Clinician Input Patient Input

EffectivenessTime to Any-Cause Discontinuation

CATIE Clozapine Pathway Results

McEvoy JP, et al. Am J Psychiatry. 2006;163:600-610.

71%

86%

56%

93%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

OLZ RIS CLO QUE

CATIE Clozapine Pathway

McEvoy JP et al. Am J Psychiatry. 2006;163:600-610; Citrome L. Psychiatry MMC. 2007;4(10):23-29; Citrome L and Stroup TS. Int J Clin Pract.2006;60:933-940.

NNT 3NNT 4

EffectivenessAny-Cause Discontinuation: NNT

What else do I need to know about

recovery?

Hierarchies of Outcome: Recovery is at Top

Stabilization

Remission

Recovery

Criteria for Recovery?

• Symptom remission• Vocational functioning• Independent living• Peer relationships• Duration ≥ 2 years

Is recovery best viewed as an outcome or a process?

Liberman P, et al. Int Rev Psychiatry. 2002;14:256-272.Liberman P, Kopelowicz. Psychiatr Serv. 2005;56:735-742.

Recovery – A Matter of Perspective

• Recovery from Illness– Cure of illness, absence of illness

versus

• Recovery in Illness: being in recovery– Process of managing illness more effectively– Having a meaningful life in the community

– Moving ahead with one’s life despite illness

Davidson L, et al. Schizophr Bull. 2008;34:5-8.

Process of Recovery

The Illness

The Illness

The Person

The PersonFriendsWork

Play

FamilyThe

Illness

The Person

Factors Associated with the Potential for Positive Clinical and Functional Outcomes

• Short duration of untreated psychosis• Good early response to antipsychotic treatment• Collaborative therapeutic alliance• Supportive family/caregivers• Access to comprehensive, coordinated, and

continuous treatment• Opportunities to engage in functional activities

and receive specialized interventions• Absence of substance abuse

What about cognition in patients with

schizophrenia?

Cognitive Deficits Are the Bridge Between Brain Functioning and Functional Impairments

in Day-to-Day Life

• Cognitive deficits are a frequent and robust feature of the illness

• Cognitive deficits are present at illness onset and persist throughout the illness

• Cognitive deficits directly contribute to poor functional outcome in schizophrenia

Normative Data Compared to a Schizophrenia Sample on the RBANS Neuropsychological Test

RBANS: Repeatable Battery for Assessment of Neuropsychological Status

from standardization sample

0.4%0% 0% 0%

16.5%

7.2%

22.8%20.6%

22.6%

7.9%

2.2%0.4%

1.6%

7.0%

16.0%

25.0%

0%

16.0%

0.4%

1.6%

7.0%

25.0%

0

5

10

15

20

25

30

35

< 50-50 51-60 61-70 71-80 81-90 91-100 101-110 111-120 121-130 131-140 140+

Total Scale Score

% o

f Cas

es

Schizophrenia (n = 575)Normal controls (n = 540)

Wilk CM, et al. Schizophr Res. 2004;70(2-3):175-186.

Components of Psychosocial Rehabilitation

Outcomes• Functional • SubjectiveMotivational

Aspects• External• Intrinsic

Social Cognition• Emotion processing• Social perception• Attributional bias• Theory of mind

Neurocognition• Attention• Processing• Memory• Reasoning• Verbal learning• Visual learning

Kurzban S, et al. Curr Psychiatry Rep. 2010;12:345-355.

Cognitive Remediation• Behavioral treatments that specifically target:

– Memory– Attention– Executive functioning– Reasoning

• Restorative cognitive techniques – drill and practice– Paper & pencil tasks– Computerized training software

COGPACK, Posit Science Brain Fitness, etc.– Individual– Groups– Compensatory cognitive training – promote adaptive behavior

• Enhance daily functioning – School, work, social interactions, independent living

• Enhance skills pertinent to recovery goals

Medalia A, Choi J. Neuropsychol Rev. 2009;19:353-364.

Work and Schizophrenia

Barriers• Cognitive impairments• Psychiatric symptoms• Episodes of illness• Stigma from employers• Internalized stigma/low self-confidence• Fear of losing disability benefits

McGurk S, et al. Schizophr Bull. 2009;35:319-335.Kurzban S, et al. Curr Psychiatry Rep. 2010;12:345-355.

~20% employed

80% Unemployed

55–70% identify employment as a goal

Vocational Rehabilitation

McGurk S, et al. Schizophr Bull. 2009;35:319-335.Kurzban S, et al. Curr Psychiatry Rep. 2010;12:345-355.

• Skills training• Sheltered workshops• Transitional employment• Supported employmentVocational rehabilitation + cognitive remediation → best

results

Employment =• Increased self esteem• Reduction in symptoms and hospitalizations• Enhanced social functioning• Improvement in overall quality of life

Supported EmploymentBasic Principles1. Zero exclusion; eligibility based on consumer choice2. Focus on competitive jobs in integrated community

settings3. Rapid job search4. Respect for consumers’ preferences in terms of the

nature of the job and types of support services5. Ongoing job support6. Close integration with a psychosocial rehabilitation

team approach7. Benefits counseling (disability benefits, social security,

medical insurance)

McGurk S, et al. Schizophr Bull. 2009;35:319-335.

Optimizing Employment OutcomesVocational Rehabilitation (VR) + Cognitive Remediation (CR)

McGurk S, et al. Schizophr Bull. 2009;35:319-335.

* P < 0.05; ** P < 0.01VR + CR: Greater improvements in verbal learning, memory, executive functioning vs VR only

0

5

10

15

20

25

30

35

40

45

CompetitiveCommunity

Work

Hospital-basedInternship

Total

Wee

ks W

orke

d

VRVR + CR

0

500

1000

1500

2000

2500

3000

Wag

es E

arne

dCompetitiveCommunity

Work

Hospital-basedInternship

Total

**

*

*

Cognitive remediation with COGPACK training software

What can guidelines tell us?

Management of Schizophrenia

• Patient-focused therapeutic alliance• Individualized approach• Reduce or eliminate symptoms• Optimize quality of life• Assist patients in attaining personal life goals (work,

housing, relationships)• Guidelines and algorithms provide a framework for

decision making

Guideline/Algorithm RecommendationsAPA TMAP PORT

2004 2006 2009

First episode SGA SGA SGA, FGA

Second choice SGA, FGA, C SGA, FGA SGA, FGA

Third choice C C C

Fourth choice (C+) C+ –

Fifth choice – A,T –

Combinations – CF –

FGA: first-generation antipsychotic SGA: second-generation (atypical) antipsychotic C: Clozapine C+: Clozapine augmentationCF: Clozapine failure Practice Guideline for the Treatment of Patients with Schizophrenia. 2nd Edition. APA. 2004.Moore T, et al. J Clin Psychiatry. 2007;68:1751-1762.Kreyenbuhl J, et al. Schizophr Bull. 2010;36:94-103.

PORT Psychosocial TreatmentPatient Outcomes Research Team

Recommendations for:

• Assertive community treatment

• Supported employment

• Skills training

• Cognitive behavioral therapy

• Token economy interventions

• Family-based services

• Interventions for alcohol and substance abuse disorders

• Interventions for weight management

Dixon L, et al. Schizophr Bull. 2010;36:48-70.

What is it that we actually do?

Survey of APA Practice Research Network: Schizophrenia Treatments

West J, et al. Psych Services. 2005;56:283-291.

Real-World Antipsychotic Treatment Practices

Moore T, et al. Psychiatr Clin N Am. 2007;30:401-416.

• Second-generation antipsychotics are used in over 70% of individuals with schizophrenia (use may be higher in first-episode patients)

• Rate of clozapine use is much lower than the incidence of treatment-resistant schizophrenia

• Antipsychotic polypharmacy – ~10 to 30% of individuals with schizophrenia

– FGA + SGA most common combinations

• Use of adjunctive medications– Baseline data from CATIE

Antidepressants (38%), anxiolytics (22%), sedative hypnotics (19%), lithium (4%), other mood stabilizers (15%)

• Dosage of antipsychotic medications within therapeutic range 64 to 83% of the time during inpatient treatment

What do we know about efficacy and

tolerability of antipsychotic medication?

Leucht S, et al. Lancet. 2009;373(9657):31-41.

Amisulpride ZotepineZiprasidoneSertindoleRisperidoneQuetiapineOlanzapineClozapineAripiprazole

SGA versus FGA

Meta-Analyses Demonstrate the Heterogeneity for Antipsychotic Response

“All antipsychotics are equal, but some are more equal than others” - Volavka J, Citrome L. J Clin Psychiatry. 2009;70:429-430.

Meta-Analyses Demonstrate the Heterogeneity for Antipsychotic Response

“All antipsychotics are equal, but some are more equal than others” - Volavka J, Citrome L. J Clin Psychiatry. 2009;70:429-430.

Leucht S, et al. Am J Psychiatry. 2008;166(2):152-163.

Advantages for:

ClozapineOlanzapineRisperidone

SGA versus SGA

Antipsychotics – Heterogeneity for TolerabilityEPS, Prolactin, Weight, Glucose/Lipids, Sedation, Hypotension

Volavka J, Citrome L. Expert Opin Pharmacother. 2009;10(12):1917-1928.

CATIE – Reasons for Discontinuation

74%

24%

15%

30%

6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

ALL CAUSE LACK OFEFFICACY

INTOLERABILITY PATIENTDECISION

OTHER REASONS


4.0%1.8%

4.9%

4.0%

WEIGHT GAIN - METABOLIC EFFECTS EXTRAPYRAMIDAL EFFECTS

SEDATION

OTHER

N=1432

How do we manage this heterogeneity?

ClinicalJudgment

RelevantScientificEvidence

EBM

Patients’ Values and Preferences

We Can Use Evidence-Based Medicine

Sackett DL, et al. BMJ. 1996;312(7023):71-72.

Citrome L, Ketter TA. Int J Clin Pract. 2009;63(3):353-359.

EfficacyDoes Rx reduce

Sx?

Tolerability and SafetyDoes Rx cause

SE?

Adherence/PersistenceWill Pt take Rx?

Lehman AF, et al. Am J Psychiatry. 2004;161(2 suppl):1-56.Swartz MS, et al. Schizophr Bull. 2003;29(1):33-43.Lieberman JA, et al. N Engl J Med. 2005;353(12):1209-1223.

What Is Treatment Effectiveness?

TreatmentEffectiveness

Combines all measures

Effective Use of Medication

• Medication is a tool that a person with schizophrenia can use to take greater control over his or her life

• The goal should be to maximize the effectiveness of medication to help the person live the kind of life that he or she wants to live

• The medicine has work well enough, be tolerated well enough, and the patient has to take it

Medication Nonadherence

Lacro J, et al. J Clin Psychiatry. 2002;63:892-909.Novick D, et al. Psychiatry Res. 2010;176:109-113.Masand P, et al. Prim Care Companion J Clin Psychiatry. 2009;11:147-154.

• Prevalence ~30 to 50% (and higher); rates vary depending on clinical setting, definitions, study duration, study population

• Relatively short gaps in medication coverage can increase the risk of relapse

• Nonadherence is associated with poor outcomes–Relapse–Hospitalization–Suicide attempts

How can we manage non-adherence?

Step 1: Admit the possibility of partial or

nonadherence

We Overestimate Adherence

– Nonadherence viewed as failure → consistent bias to overestimate adherence/underestimate nonadherence

– We assume lack of adequate response as “treatment-resistance” and lack of efficacy for the antipsychotic for that patient This is a possible explanation for high dosing of antipsychotics,

polypharmacy with other antipsychotics and combination treatment with anticonvulsants – This is a no-win cycle: adherence is even more of a

challenge with complex regimens

Velligan DI, et al. Psychiatr Serv. 2007;58(9):1187-1192.

Step 2: Identify the specific barriers to

adherence present for your patient

Risk Factors for Nonadherence

1. Velligan DI, et al. J Clin Psychiatry. 2009;70(suppl 4):1-46.2. Lee S, et al. Soc Sci Med. 2006;62(7):1685-1696.

Patient-related1

• Poor insight• Negative attitude

toward medication • Prior nonadherence • Substance abuse• Cognitive impairment

Treatment-related1

• Side effects• Lack of efficacy/

continued symptoms

Environment/Relationship-related1

• Lack of family/social support• Problems with therapeutic alliance• Practical problems

(financial, transportation, etc)

Societal-related2

• Stigma attached to illness• Stigma caused by medication

side effects

Barriers to Therapeutic Alliancein Schizophrenia

● Patient barriers1

– Communication difficulties – Difficulty forming an alliance because of negative symptoms – Difficulty learning from experience because of cognitive

symptoms – Rejection of diagnosis due to stigma

● Clinician barriers2

– Underestimating importance of relationship – Hopelessness conveyed to patient – Lack of interest in life goals and other issues important to patient

1. Velligan DI, et al. J Clin Psychiatry. 2009;70(suppl 4):1-46.2. Pitschel-Walz, G, et al. J Clin Psychiatry. 2006;67(3):443-452.

Relationship Between Early Alliance and Later Medication Adherence: The Boston Collaborative Study

Frank AF, Gunderson JG. Arch Gen Psychiatry. 1990;47:228-235.

74

26a 28a

0

20

40

60

80

Good Fair Poor

Alliance at 6 Months

Adh

eren

ce A

fter 6

Mon

ths,

%

aP < 0.001

Assessing Medication Adherence: Interview Style

● Ask for the patient’s view about medications1,2 ● Obtain sufficient information before responding3 ● Do not jump to conclusions; take comments at face value3

● Explain that you want to hear what the patient really thinks, not what he/she thinks you want to hear1-3

● If you want to respond, do not try to do too much and make sure you do not go beyond what the patient can accept for now

● As much as you can, try to keep the discussion about medication adherence positive—even enjoyable1

● Above all, try to maintain and even strengthen the alliance, even if there is disagreement about the need for medication1

1. Weiden, PJ. J Psychiatr Prac. 2002;8(6):386-392.2. McCabe R, et al. BMJ. 2002;325(7373):1148-1151.3. Weiden PJ. J Clin Psychiatry. 2007;68(suppl 14):14-19.

Assessing Medication Adherence: Interview Style

“Have you been taking your medications?” or “You have been taking your medicines, right?”

“Everyone misses doses of their medicines. Can you give me some idea of how many doses do you usually miss in any given week? I just need a ball-park figure, you don’t have to be exact.”

This is followed by, “What doses do you miss the most – morning? evening? with meals? in between meals? This way we can figure out the best time of day to use these medications so we can minimize the number of times you may miss them.”



Patient-related1



Treatment-related1


continued symptoms




Societal-related2


side effects

Medication-related Side Effects and Nonadherence

● Potential drivers– Level of distress rather than severity– Attribution to the medication– Vary from patient to patient

● Most commonly associated with nonadherence– Weight gain– Sedation– Akathisia– Sexual dysfunction– Parkinsonian symptoms– Cognitive problems

Velligan DI, et al. J Clin Psychiatry. 2009;70(suppl 4):1-46.

Reverberations From Side Effects How Patient and Clinician Responses May Differ

Side effectappears

Subjective Distress

Objective Severity

Adherence Impact

Safety and Risk

Influencing patient response

Influencing clinician response

Weiden PJ, Buckley PF. J Clin Psychiatry. 2007;68(suppl 6):14-23.

Considering Side Effect Profile When Choosing Treatment

Important because side effects may1:– Contribute to treatment nonadherence– Limit return to maximal levels of social functioning– Potentially contribute to long-term morbidity

Atypical antipsychotics are better tolerated than typical antipsychotics (mainly due to decreased EPS)2

Differences in drug-specific adverse effect profiles, including metabolic effects, may impact treatment adherence and long-term outcomes1,2

1. Velligan DI, et al. J Clin Psychiatry. 2009;70(suppl 4):1-46.2. Tandon R. Psychiatr Q. 2002;73(4):297-311.



Patient-related1



Treatment-related1


continued symptoms




Societal-related2


side effects

What Type of Intervention Is Appropriate?

● If the adherence problem is that the patient WILL NOT, focus intervention on strengthening perceived benefits of medication and minimizing perceived costs

● If the adherence problem is that the patient CANNOT, then address barriers to adherence

– Pill boxes in obvious locations – Self-monitoring tools– Establishment of routines– Consider long-acting injectable antipsychotic

Weiden P. J Clin Psychiatry. 2007;68(suppl 14):14-19.



Patient-related1



Treatment-related1


continued symptoms




Societal-related2


side effects

Step 3: Monitoring adherence

Monitoring Medication Adherence● There are no entirely satisfactory methods, but can

count pills and measure plasma levels● Ask if the patient is taking his/her medications● Ask, are the medications doing any good?

– Any perceived benefit (eg, sleeping better) is a treasure

– If none, be worried● Ask, are the medications doing any harm?

– Ask about being sleepy, slowed down, dulled – Ask about weight changes – Ask about constipation – Ask about sex

Velligan DI, et al. J Clin Psychiatry. 2009;70(suppl 4):1-46.

Step 4: Consider a depot antipsychotic

Considering Efficacy When Choosing Treatment

Someone who isn’t responding adequately to an oral medication is unlikely to then respond to its depot formulation Unless they were a non-responder because of nonadherence

There is heterogeneity in efficacy outcomes among the different antipsychotics, and this heterogeneity is observed among groups in clinical trials and in individual patients

Potential Advantages of Long-acting Injectable Antipsychotics

Reduces dosage deviations1

Eliminates guessing about adherence status2,3

Shows start date of nonadherence2,3

Helps disentangle reasons for poor response to medication3

Eliminates need for the patient to remember to take a pill daily1

Enables prescribers to avoid first-pass metabolism, therefore a better relationship between dose and blood level exists1

Results in predictable and stable plasma levels1

Eliminates abrupt loss of efficacy if dose missed1,3

Many patients prefer them, especially if already receiving them4

1. McEvoy JP. J Clin Psychiatry. 2006;67(suppl 5):15-18.2. Olfson M, et al. Schizophr Bull. 2007;33(6):1379-1387.3. Kane JM, et al. J Clin Psychiatry. 2003;64(suppl 12):5-19.4. Patel MX, et al. J Psychiatr Ment Health Nurs. 2005;12(2):237-244.

Potential Obstacles to Long-acting Injectable Antipsychotics

Lack of infrastructure in outpatient settings Need to refrigerate, store, reconstitute, etc. Overburdened public agencies Frequency of injections and consequent inconvenience

for staff and patients Need to take concomitant medications orally Anti-shot sentiment

McEvoy JP. J Clin Psychiatry. 2006;67(suppl 5):15-18.Kane JM, et al. J Clin Psychiatry. 2003;64(suppl 12):5-19.

Determinants of Depot Use

Citrome L, et al. Psychopharmacol Bull. 1996;32(3):321-326.

Favors Treatment.1 .2 1 5 10

Favors Control

Barnes 1983 3/19 3/17

Falloon 1978 8/20 5/24

Hogarty 1979 22/55 32/50

Quitkin 1978 5/29 4/27

Rifkin 1977 1/19 4/24

Crawford 1974 2/14 6/15

DelGuidice 1975 21/27 59/61

Schooler 1973 26/107 35/107

Total (95% CI) 88/290 146/325

StudyTreatment

n/N Control

n/NRelative Risk

(95% CI Random) Relative Risk(95% CI Random)

0.89 (0.21, 3.85)

1.92 (0.74, 4.95)

0.62 (0.43, 0.92)

1.16 (0.35, 3.89)

0.63 (0.06, 6.45)

0.36 (0.09, 1.48)

0.80 (0.65, 0.99)

0.74 (0.48, 1.14)

0.78 (0.66, 0.91)

Overall effect z = 3.06; P = 0.002

Depot Antipsychotics Reduce Relapse in Long-term Studies

Mentschel C, et al. Presented at: The International Congress on Schizophrenia Research (ICOSR) 2003; March 29-April 2; Colorado Springs, Colorado.

Relapse-free Survival Rates With Oral and Depot Fluphenazine

0 3 6 9 12 15 18 21 24Months in Community

Hogarty GE, et al. Arch Gen Psychiatry. 1979;36(12):1283-1294.

Oral fluphenazine (n = 50)

Fluphenazine decanoate (n = 55)

987654

10

3

Prop

ortio

n Su

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ing

012

Adherence Summary Strategies to improve adherence include

– Admitting that partial or nonadherence is a possibility– Identifying risk factors specific to the individual– Addressing barriers to therapeutic alliance– Tailoring interventions to adherence attitudes and

behavior Pharmacologic strategies to improve adherence include

– Considering patient history, efficacy, and side effect profile when choosing treatment

– Considering utilizing long-acting injectable antipsychotics, if available, in patients with recurring relapses related to nonadherence

Summary• Response, remission and recovery are necessary goals of

treatment, but each can be interpreted differently by clinicians, patients, and their families

• Clinical practice guidelines can provide advice regarding a comprehensive approach, unfortunately not often done

• Treatment effectiveness is dependent on a medication being efficacious enough, tolerable enough, and the patient has to take it

• Adherence can be the ultimate confounder regarding effectiveness

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practical strategies for the treatment of patients with schizophrenia leslie citrome, md, mph...

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