During the EPA in Vienna 2015 we spoke with Professor Andreas Meyer-Lindenberg of the Central Institute of Mental Health, Mannheim, Germany and the Department of Psychiatry and Psychotherapy, University of Heidelberg. Professor Meyer-Lindberg originally envisaged a career in neurology but from his first taste of psychiatry he was hooked by the unique patient-physician relationship and opportunity to get to know the whole patient portrait. Here we capture highlights of a longer video interview that can be seen on the on-line educational programme psychiatryspeaks.com.
How would you describe patient autonomy in schizophrenia?
Autonomy is one of the goals of treatment. It is also something that needs to be seen as part of the disease concept. Patients might not articulate the term autonomy but if their autonomy is impaired by their condition and if they don’t feel they are in the driving seat this can affect the psychiatrist patient relationship.
Do the psychiatrist’s treatment goals and those of the patient always align?
As clinicians our goals are to keep the patient safe, avoid suicidality and work on the disease concept with the patient. That means not just controlling symptoms but also helping with aspects such as motivation, social and work based reintegration. That tends to be our hierarchy.
Patients on the other hand may have a different hierarchy and they might feel controlled by physician-set goals. They may want to achieve certain things, want to avoid treatment side effects, and that’s why dialogue with the patient is so key.
Where do caregivers fit when communicating with patients?
Caregivers can be crucial. Patients with schizophrenia are often young when they first fall ill and the disease can disrupt education and family life. It can be scary and difficult to deal with, and treatment plans and care need to include caregivers. One of the most solid pieces of evidence we have is that when we don’t work with family and carers, relapse rates increase.
Carers can provide a lot of information and we can also provide them with a lot of information: helping the patient and carers separate what features are due to the illness and shouldn’t be criticized as behaviours for example.
How do you help patients and caregivers?
The therapeutic setting is important and we explain what networks there are for patient and carers. It’s all about working on a relationship. We can provide information about the likely course of disease and the options to help patients make the choices that are right for that patient. We want to convey that schizophrenia is not necessarily a chronic debilitating illness.
Often people are so afraid of the diagnosis but when they understand what can be done to deal with schizophrenia and that there can be long stretches when the patient is fine, they feel reassured.
Can we talk about the long-term nature of schizophrenia?
It is often a chronic illness but on the other hand, we can tell patients who have one psychotic episode that there is a greater than 25% chance this will be their only episode. I always give patients a picture of likely scenarios and tell them not assume they will fall into the worst case scenario.
For patients who do receive a schizophrenia diagnosis and have relapses we let them know there is always something that can be done and it is never a hopeless situation. Schizophrenia ‘sucks’ but hope is never lost.
What is the potential for patients with schizophrenia?
Prognosis in schizophrenia is a hard concept to capture. Some patients score low on schizophrenia assessment scales yet are happy and sometimes very simple achievements can boost a patient’s confidence and happiness.
So we take a broader view than just symptom control and look at prognosis from the patient viewpoint.
