After a well-received satellite symposium at ECNP 2015 on functioning and quality of life (QoL) as long-term treatment goals in schizophrenia, our correspondent caught up with the chair of that session, Professor Dieter Naber, Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany, to discuss some of his thoughts on treatment goals and options.
To what extent do you think psychiatrists need to increase their focus on improving functioning and QoL of their patients with schizophrenia when making treatment decisions?
Psychiatrists need to increase their focus on these areas a great deal. In the early years of antipsychotic therapy, there was no scientific interest in these aspects of the disease, or on the patient’s perspective for around 20 years. This was partly because psychiatrists believed that patients were not able to self-rate their disease status in a meaningful way. They also considered this assessment unnecessary, as the psychiatrists knew the patients well, so this additional information was not needed. However, now we know those patients are of course capable of self-rating, and that their perspective is different from that of their psychiatrist, so these assessments are both valid and important. Over the past 10–15 years there has been increasing research interest in patient QoL in schizophrenia, but there is still room for improvement.
When you think about your patients, what do they experience as improvements in functioning and QoL? What matters to them and how do they talk about it during consultations?
This, of course, varies from patient to patient. Most patients want a normal life: to have a relationship, get back to work, etc. although this is not so easy. A big factor in improving outcomes for patients is to avoid major side-effects. With more drugs available in the last 10 years, it is now possible to individualise treatments, to avoid intolerable side-effects and to take greater account of patients’ individual treatment goals. Now we talk about shared decision-making with the patient. In this way, there is a much greater chance of adherence to the chosen therapy.
With the therapeutic options at your disposal today, what do ‘outcomes’ for people with schizophrenia look like?
In the past, managing tolerability was a big issue in treatment outcome. This is not the case nowadays so we can be more ambitious. For younger adult patients, it is often relatively easy to restore their prior level of functioning, and it is important that they are able to return to work. Discussing schizophrenia with the patient is tricky – you need to strike a balance between stressing the seriousness of the illness and the need for long-term treatment, alongside instilling hope in the patient and confidence in treatment outcomes. Nevertheless, encouraging the patient to take any drug for a long period is a major task. The therapeutic alliance is very important in this: the patient needs to know that their psychiatrist is really interested in their life and how they are managing.
In your opinion, what role can newer generations of atypical long acting injectable antipsychotics (aLAIs) play in improving the outcomes for people with schizophrenia, and why?
These drugs are important in helping improve treatment tolerability and patient adherence. Patients’ families also often like these drugs, as the injection removes their need to monitor and try to manage the patient’s treatment adherence, so taking away a great burden from the family dynamic.
If there were three pieces of advice you would give your fellow psychiatrists around getting the most out of an aLAI as a treatment option, what would they be?
Firstly, offer these drugs to patients as early as possible in their disease course: this treatment option should be considered and offered to patients who have had a first episode of schizophrenia. Secondly, include the parents and caregivers in your discussions and decision-making. Sometimes patients do not want their family informed of their condition while they are in psychosis. However, whenever possible the psychiatrist needs the family’s experience and advice, to know more about the patient. Thirdly, maintain the therapeutic alliance. Make agreements with the patient about what you will do if they do not come to receive their injection, and use the regular treatment appointments as an opportunity to make other psychosocial interventions, such as psychoeducation for them and their family.
