Improving Patient Outcomes in Schizophrenia: Achieving Remission, Preventing Relapse, and Measuring Success

John M. Kane, MD

Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks; the Department of Psychiatry, Hofstra North Shore-Long Island Jewish School of Medicine, Uniondale; and Behavior Health Services, North Shore-Long Island Jewish Health System, New Hyde Park, New York

Schizophrenia can be a discouraging diagnosis for patients due to its chronic nature, but a strong therapeutic alliance with a clinician and support from family can greatly improve patient outcomes. When treating an acute schizophrenic episode, the goals are response to the intervention, resolution of the episode, and eventual symptom remission, with the ultimate goals of avoiding relapse and achieving recovery (AV 1). To achieve these goals and optimally treat schizophrenia, clinicians should move through the following phases: (1) measuring response, (2) achieving remission, (3) preventing relapse, and (4) aiming for recovery.

AV 1. Treatment Progression and Symptomatic Improvement in Schizophrenia Over Time (00:42)

 

Measuring Response

After initiating treatment for a patient in an acute episode, clinicians should begin measuring response. Clinicians may use the CGI to gauge patient response by asking if the patient is better overall and, if so, by how much; however, this method may not be reliable or sensitive enough to accurately guide clinical decisions. Instead of relying on global assessments, clinicians can consistently measure and quantify treatment response using more detailed and thorough rating scales, such as the BPRS or PANSS, and then use those data to set treatment targets and goals. Using baseline and follow-up scores, if a patient shows a lack of symptom improvement or symptom worsening or has side effects, clinicians can work through a checklist of reasons for inadequate treatment response and re-evaluate the diagnosis, the medication, the dose, and patient adherence. If nonadherence is hindering response, clinicians should educate the patient and elicit the support of family or caregivers. Once nonadherence is addressed, clinicians can make decisions regarding a change in dose, a switch or the use of an additional medication, or a nonpharmacologic option like cognitive-behavioral therapy.

Achieving Remission

Defining remission helps patients and families to establish reasonable expectations and perceptions of the illness and allows clinicians and researchers to compare patient outcomes, make judgments about clinical practice, and focus on improving long-term outcomes. Remission is achieved when a patient scores mild or less on all of the following 8 signs and symptoms from the PANSS (comparable items can also be identified on the BPRS) for at least 6 months1:

  1. Delusions
  2. Conceptual disorganization
  3. Hallucinatory behavior
  4. Unusual thought content
  5. Mannerisms and posturing
  6. Blunted affect
  7. Social withdrawal
  8. Lack of spontaneity/flow of conversation

These remission criteria can be used cross-sectionally for data collection, and they are easy to apply in routine practice. Although this definition of remission may seem like an unrealistic goal with the fluctuating course of schizophrenia and the heterogeneity of its treatment response, studies2-4 show that 29% to 45% of patients with schizophrenia achieve remission. The challenge for clinicians is to increase that proportion.

Preventing Relapse

One of the main barriers to recovery is relapse, or an acute psychotic exacerbation significant enough to warrant either a change in medication or hospitalization. Relapse may include an increase in aggressive behavior or suicidality, but it is often a mixture of symptoms and behaviors. Therefore, the clinicians must use their judgment combined with assessment scale results to determine if a relapse has occurred.

AV 2. Helping a Patient With Schizophrenia Avoid Relapse (02:17)

 

Consequences of relapse. Relapses worsen the progression of schizophrenia, causing more hospital stays and increasing the risk of treatment resistance, self-harm, and homelessness.5 With each relapse, patients can have a harder time regaining previous levels of functioning, which may damage their self-esteem and cause social and vocational disruptions (AV 2). Relapsing patients also require greater use of health care resources and more support from families and caregivers than those in stable recovery.6

Importance of adherence. Because the risk of relapse is high when patients stop taking medication, encouraging patients to adhere to their treatment regimen is a priority for preventing relapse.7 In the 5 years following a first episode of schizophrenia, 82% of patients have at least 1 relapse, and discontinuing antipsychotic treatment increases the risk of relapse by almost 5 times.8 To prevent relapse, particularly in such a disabling disorder, clinicians should keep patients on the same medication that helped them achieve remission and look for ways to improve patients’ adherence through education, support, or optional delivery systems such as injectable antipsychotics. Injectable antipsychotics provide continuous medication delivery, which can improve symptom control and prevent relapse, especially in patients who are nonadherent on oral medication.

More

Continuous versus intermittent treatment. Continuous medication prevents relapse better than an intermittent strategy of giving treatment only when patients start showing signs of clinical deterioration.9 Expecting patients to recognize early signs of relapse and start taking medication again is unreliable—they may lose insight before restarting the medication or they may not be prepared or eager to go back on medication, causing an acute episode with possible hospitalization. But, when treatment is continued during the maintenance phase of the illness, the risk of relapse decreases substantially.8

AV 3. Proposed Factors Linked to Achieving Recovery in Schizophrenia (00:38)

Adapted with permission from Liberman et al10

Aiming for Recovery

The 4 UCLA criteria for recovery are (1) symptom remission, (2) appropriate role function at work or school (at least part-time), (3) independent living, and (4) the maintenance of peer relationships (AV 3).10 Improvement in each domain must be achieved and sustained concurrently for at least 2 years. This is a challenging but attainable goal for patients with schizophrenia. In a 5-year study,11 14% of first-episode patients with schizophrenia reached the recovery stage.

Patients who relapse must again achieve response and remission and then meet the criteria for 2 years to be considered recovered. Clinicians can increase the number of patients who reach recovery by preventing relapse through emphasizing adherence and continuous maintenance treatment.

Conclusion

For patients with schizophrenia, the path to recovery may be daunting, but it is attainable. When managing the first acute episode, clinicians must initiate treatment and measure response, striving for the patient to experience remission of symptoms. Routinely using rating scales during this process can aid clinical decision-making and help document patient progress. Once remission is achieved, clinicians must continue patients’ medication and actively promote treatment adherence in order to prevent relapse, particularly since every relapse impedes recovery and makes returning to premorbid levels of functioning difficult. Although patients with schizophrenia cannot expect a cure for their condition, they can reach recovery and regain independence, the ability to work and to enjoy social relationships.

Clinical Points

  • Use a rating scale, such as the BPRS or PANSS, to measure treatment response
  • Prevent relapses by monitoring patient adherence and continuing medication throughout the maintenance phase of treatment
  • Educate patients and their families about the importance of adherence to achieving the ultimate goal of recovery

Abbreviations

BPRS = Brief Psychiatric Rating Scale
CGI = Clinical Global Impressions Scale
PANSS = Positive and Negative Syndrome Scale
UCLA = University of California, Los Angeles

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References

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