Beyond Symptom Control: Optimizing Functional Outcomes in Schizophrenia Care

Announcer:
You’re listening to NeuroFrontiers on ReachMD, and this episode is sponsored by Bristol Myers Squibb. Here’s your host, Ashley Baker.

Ashley Baker:
This is NeuroFrontiers on ReachMD, and I'm psychiatric nurse practitioner Ashley Baker. Joining me to discuss integrated care approaches that can help improve functional outcomes in patients with schizophrenia is Dr. Stephen Marder. He's the Distinguished Professor of Psychiatry at the Semel Institute for Neuroscience at UCLA, the Director of the UCLA section on psychosis, and the Director of the VA VISN 22 Mental Illness Research Education and Clinical Center. Dr. Marder, welcome to the program.

Dr. Marder: 
Thanks. I'm glad to be here.

Ashley Baker: 
Well, to start us off, Dr. Marder, can you tell us how the definition of recovery in schizophrenia has evolved beyond just symptom control?

Dr. Marder: 
Yeah, the idea of recovery was really promoted by patients, family members, and advocates for people with serious mental illnesses several years ago. It focused on the fact that clinicians oftentimes tended to focus on symptoms—and in the case of schizophrenia, symptoms such as hallucinations and delusions—whereas the goal of patients and those who care about them was more in the range of the quality of their lives and their ability to function in their communities.

There's also a tendency among mental health providers to be overly pessimistic about the outcome of schizophrenia, to believe in this idea that people who are burdened by symptoms were unable to thrive. When in fact, there's ample evidence that even patients who have a substantial symptom burden of hallucinations, delusions, and misinterpretations of things happening around them are often able to cope with those symptoms and still work and have meaningful and fruitful lives, particularly when treatment doesn't just focus on their symptoms but also focuses on their strengths. And I think that this has really changed many of the concerns of clinicians and has been highly successful.

Ashley Baker: 
Now, in practice, what barriers or challenges might keep patients from achieving functional recovery, even if their symptoms are stabilized?

Dr. Marder: 
In contrast to the beliefs of many clinicians, the ability of patients to function in their communities and to have a functional recovery is not strongly related to the severity of their symptoms. The symptom severity may determine whether they need to be hospitalized and how often they're hospitalized. But the ability to achieve a functional recovery is much more related to other symptom domains, which are intrinsic to schizophrenia. And these include the impaired cognition—things like memory, attention, and short-term memory are affected—and negative symptoms, like apathy and disinterest, particularly disinterest in social activities—that's very common in people with schizophrenia. But these symptoms are much more strongly related to the ability of patients to have a functional recovery. Even when patients are symptomatically stable, they can still demonstrate the impairments in these other symptom domains and can also demonstrate an improvement.

Ashley Baker: 
So then given those challenges, let's zero in on some potential solutions. What role do integrated care models and non-pharmacologic interventions play in supporting long-term functional recovery?

Dr. Marder: 
I'm going to talk about an integrated model that includes both pharmacotherapy and other kinds of non-pharmacological treatments. The role of pharmacotherapy is to stabilize the symptoms that patients are experiencing, particularly the hallucinations, delusions, and misinterpretations that they may have.

Once the patients are pharmacologically stable, patients can benefit from other symptoms, which are not adequately treated by pharmacotherapy. So for example, many patients who are adequately treated with medications will continue to have lingering symptoms of psychosis, such as hallucinations and delusions. Cognitive behavior therapy for psychosis focuses on those positive symptoms and can oftentimes be very effective, where the symptoms may not go away entirely, but patients learn how to compensate and live with those symptoms.

For patients who have cognitive impairments—problems in attention, memory, and decision-making—cognitive remediation can be very effective. This is usually delivered by internet programs that help patients improve their cognitive abilities. But there are other effective treatments. For patients who have impairments in social skills and social cognition—they have problems recognizing social signals that most of us are familiar with—these treatments can really help them flourish more socially.

For other patients, supported employment and education can be helpful. So for example, patients who've experienced that first episode of schizophrenia may find that they need additional help in order to return to school or return to the workplace. And integrating employment specialists and educational specialists into psychiatric treatment can give patients the support that they need in order to get these other treatments and do well.

Ashley Baker: 
For those just tuning in, you're listening to NeuroFrontiers on ReachMD. I'm psychiatric nurse practitioner Ashley Baker, and I'm speaking with Dr. Stephen Marder about how and why functional recovery—and not just symptom reduction—is becoming the driving goal in schizophrenia care.

So if we continue to examine ways we can support functional recovery, Dr. Marder, how important is it to incorporate patient-defined goals into treatment planning? And what impact can this have on outcomes?

Dr. Marder: 
I think it's really essential when meeting with the patient early on and forming treatment goals that we get behind their goals. For many patients when they come in to see a psychiatrist or a psychiatric nurse practitioner, what they have in mind is their own personal goals—whether it's school, work, or fulfilling family responsibilities—and the treatment should be focused on that. Many patients have trouble staying on their medications, for example; when they see adherence to treatment as part of helping them reach goals, it becomes essential.

The other thing—it's something I mentioned previously—is not just assessing a person's goals, but their individual strengths. For example, some patients who are really cognitively intact or have good cognitive abilities can use reasoning, problem solving, and other strategies to deal with psychotic symptoms and other impairments. So I think understanding a patient's strengths and their goals is essential.

Ashley Baker: 
Now, treatment tolerability often gets overlooked. But how can medication side effect burden affect a patient's ability to participate in recovery activities? And are there any ways we can reduce that burden?

Dr. Marder: 
Well, there are a couple of things. One is medication side effects—whether it's sedation, substantial weight gain, or feeling anxious and uncomfortable due to medications—all of these things can affect a person's self-confidence and their ability to function in the community. For example, patients who've had large and substantial weight gain can have changes in their self-esteem and their self-confidence in dealing with social interactions. And these can limit their ability to function.

And although they're effective in treating symptoms, the antipsychotic medications that have been prescribed but that were only available up until recently also had a tendency to affect the amount of energy and interest in things. There's a process in which patients, in order to stay motivated—well, for all of us to stay motivated—we anticipate that social interactions and other activities will be rewarding. And antipsychotic medications can actually diminish that, and they diminish a bit of the quality of life. So really minimizing those symptoms, I think, is essential to helping patients flourish and do better.

Ashley Baker: 
Lastly, Dr. Marder, what larger systemic changes are needed to make functional recovery a true standard of care?

Dr. Marder: 
Well, one is that the way that treatments are reimbursed. Drug treatments are usually well reimbursed, but the psychosocial treatments—things I've talked about like supported employment, education and cognitive behavior therapy for psychosis, social skills, and social cognition training—these very effective treatments are really poorly reimbursed or it's difficult to get reimbursement. And also, it's hard to find practitioners who actually have the skills to administer these treatments. So I think improvements in the way that payers reimburse for psychiatric treatment and getting more clinicians, particularly psychotherapists, trained can make a big difference. And of course, improvements in pharmacotherapy—drugs with less side effects or adverse effects that diminish quality of life—can really contribute to better long-term outcomes for people with schizophrenia.

Ashley Baker: 
As those final comments wrap up today's program, I want to thank my guest, Dr. Stephen Marder, for joining me to discuss approaches to improving functional outcomes among patients with schizophrenia. Dr. Marder, it was great having you on the program.

Dr. Marder: 
Thanks. I was glad to join.

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You've been listening to NeuroFrontiers on ReachMD, and this episode is sponsored by Bristol Myers Squibb. To access this and other episodes in our series, visit NeuroFrontiers on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!