John M. Kane, MD: Jeffrey, what do you think about, in terms of preventing hospitalization? How big of a factor is relapse in our desire to prevent hospitalizations?
Jeffrey A. Lieberman, MD: Well, the biggest factor to prevent hospitalization is insurance. If you do not have insurance, you don’t get admitted.
T. Scott Stroup, MD, MPH: Are you recommending that?
Jeffrey A. Lieberman, MD: Well, I think it would be nice if our country developed a health care policy and financing system that invested in the needs of the entire population.
T. Scott Stroup, MD, MPH: I agree.
Jeffrey A. Lieberman, MD: The issue of adherence is a problem, as you mentioned, in all disease areas and specialties of medicine, but it’s more of a problem in psychiatry and with mental disorders, and more so maybe in schizophrenia because of the effect on cognitive function and insight. But if you think adherence can be, “Oh, I forgot to take my medicine,” or, “I didn’t get my disability check, so I couldn’t get to the pharmacy to pick up my prescription,” those are just logistical things.
But doctors also have to be very sensitive to the other factors that foment nonadherence adverse effects. When you prescribe a dose of medicine that is therapeutically effective, how closely do you evaluate the adverse effects that patients may be experiencing and could impel them to not want to take it? And then you need to try and do something to mitigate those issues, whether it’s by lowering the dosage, adding a medication that counteracts the effects, or switching them to another antipsychotic medicine, or adjusting the dose. That has to be addressed. And to the extent that it’s an inside issue or a lack of understanding what the consequences are, through the process of further educating and engaging in a dialogue, I think those are things that can have an impact on adherence rates.
But to have a relapse and be rehospitalized is really a catastrophic complication of an illness, particularly now. Because hospitalizations don’t do what they used to do. They don’t stabilize you and get you ready to redirect your life. These are now like crisis management situations. You can come into a hospital. You can be there for a few days. They can patch you up and send you out, and then you’re on your own again. And if your aftercare doesn’t remain in place, or if you’re going to a new aftercare arrangement, who knows how good that’s going to be? So relapse is to be avoided by all costs, I think, when we think about the possibility of hospitalization under the current circumstances.
T. Scott Stroup, MD, MPH: I strongly agree that we need to be carefully monitoring for adverse effects of antipsychotic medications and managing them. There are a number of effective management strategies. But my understanding is that’s actually not the main reason why people end up stopping their medications. In our studies, people stop because they don’t perceive a benefit.
Jeffrey A. Lieberman, MD: In bipolar disorder, a big complaint that leads to this is that people feel like their emotional vibrance is dulled. And that potentially is an adverse effect that impels them to want to not take their therapy. In schizophrenia, do you think that actually isn’t a direct connection? If people are gaining weight, or if they’re experiencing restlessness, that’s not a factor?
T. Scott Stroup, MD, MPH: I think it is a factor.
John M. Kane, MD: It’s not the primary factor. I think that’s the distinction.