Putting the Pieces Together: How to Get More Out of Conversations With Adult Patients Living With Schizophrenia

An Advocate First, A Nurse Practitioner Second

As a psychiatric mental health nurse practitioner (PMHNP), one of the most critical parts of my job is looking beyond my patients’ medical charts and taking the time to get to know each one on a personal level. This means treating my patients while also acting as an advocate for their overall well-being. With a disorder as complex as schizophrenia, one of the main fears I hear from patients during our conversations is that they do not think living a “normal life” is possible again. I usually reassure them that by envisioning their future and finding—and sticking to—the right treatment plan, we can get there. Adhering to treatment can be one of the most challenging parts for anyone managing a condition, and studies show that 56% of patients living with schizophrenia struggle with medication adherence.1 This not only poses personal challenges to the patient but also causes other ripple effects. Luckily, there are a few considerations to help avoid this potential road bump and develop an individualized treatment plan that is driven by our patients’ unique needs.

Identifying Individual Barriers to Medication Adherence

There are a few themes that typically arise with my patients living with schizophrenia. One of the most common ones, which we see across a number of patients struggling with mood disorders, is medication adherence. Time and again, I see patients struggle to stick to treatment plans that rely on oral medications. Often, patients work with their providers to make temporary strides by focusing on the short term instead of taking a longer, more holistic view. Some treatments, such as schizophrenia oral medications for regular use, can be temporary solutions but may not be sustainable for patients in the long run. Whether patients are unable to refill their prescription or simply forgo taking their medications due to delusions or hallucinations, these lapses can sometimes lead to a cycle of nonadherence, and in some cases, psychotic episodes. This scenario puts patients at increased risk for other events beyond the challenges of schizophrenia such as suicidal ideation, relapse, rehospitalization, death, and disability.2-4

Recently, one of my patients, who we will name “Lisa,” was experiencing delusions that felt so real they became a threat to her physical safety. Lisa has a 20-year history of schizophrenia and a challenging treatment journey battling medication nonadherence. Lisa would often leave our clinic with medication that she would later throw in her trash. After asking some pointed questions, we learned that Lisa was doing this because her delusions made her believe that her medication was compromised. This made her question the safety of her medication, and, as a result, she would refuse to take it. I often wonder if Lisa would have found a better treatment fit earlier in her journey had someone asked more questions earlier. ?

Thinking Long-term and Seeking a Bigger Picture

While Lisa’s story is unique, I see echoes of her experience among many of my patients. The path to the right treatment plan can be complex and sometimes cyclical, but as a psychiatric NP, my job is to ask the right questions to help my care team get to the right answers. Do patients have transportation to medical appointments and the pharmacy? Are they fearful of the medication? Do they stop taking their medication when they begin to feel better? Are they forgetting to take their medication?

Each answer is a piece of a larger puzzle that contributes to a more holistic picture of a patient’s experience. By digging deeper, I am able to learn so much more about my patients and help them overcome challenges in their treatment journey that may not have surfaced otherwise.

Prescribing LAIs Earlier ?

When it comes to treatment, it is important to explore all available options with patients and decide on one that will best address the specific way their disease manifests and any patterns they have previously experienced. While we frequently start patients on an oral medication, we often reach the conclusion that oral medication is not the best long-term option as patients continue their recovery. Long-acting injectables, or LAIs, are often seen as a last resort. However, they can be effective for patients for whom oral medications are not a fit. In fact, I believe that in many cases healthcare providers should explore prescribing LAIs earlier. In Lisa’s case, switching to an LAI meant that she was able to regain some control over her life and worry less about her medication regime, which has provided her with the opportunity to better communicate and socially interact with those around her. She's also built stronger relationships with our team, which in turn has allowed us to intervene earlier and help keep her symptoms under control.

LAIs can offer many benefits for patients from a variety of backgrounds. Aside from their efficacy, they are options that are less likely to interrupt a patient’s day-to-day life. They can reduce the risk of unintentional or deliberate overdose and increase the potential for early intervention if a patient misses an appointment.5 While not for everyone—and some patients appreciate the routine of taking daily pills—LAIs have the potential to decrease rehospitalization rates with less frequent relapses than patients receiving oral medications5. Because LAIs offer dosing intervals that can be biweekly, monthly, or a few times a year6, patients have the freedom and flexibility to go about their lives without a daily schizophrenia pill, eliminating the daily reminder that they are living with schizophrenia. Similarly, they do not have to live with the fear that they may forget to take their medication or refill their prescription, which could potentially lead to an unwanted psychotic episode. Often, my patients share that this gives them peace of mind and the ability to focus on aspects of their life that are rewarding or bring them joy.

At the end of the day, acting as an advocate for our patients means listening with an empathetic ear and asking the right questions. Each visit with a patient is an opportunity to connect, listen, and offer interventions that take their unique experiences into consideration and help them to live a full, authentic life on their terms.

For more perspectives from psychiatric nurse practitioners, visit the Peerspectives series on TalkingLAIs.com.

This article reflects my own experience and opinions and was developed in joint collaboration by Janssen Pharmaceuticals, Inc., and myself. I have been paid an honorarium for my time.

Levina Kumar is a mental health advocate and psychiatric nurse practitioner currently dividing her time between practicing in a community mental health center and a private clinic. She is passionate about combating long-held cultural stigmas towards psychiatric illnesses by bringing awareness to mental health and well-being.

References:

1.?Semahegn A, Torpey K, Manu A, et al. Psychotropic medication non-adherence and its associated factors among patients with major psychiatric disorders: a systematic review and meta-analysis. Syst Rev. 2020;9(1)17. doi:10.1186/s13643-020-1274-3

2.?Sher L, Kahn RS. Suicide in schizophrenia: an educational overview. Medicina (Kaunas). 2019 Jul 10;55(7):361. doi:10.3390/medicina55070361

3.?Zhou J, Lamichhane B, Ben-Zeev D, et al. Predicting psychotic relapse in schizophrenia with mobile sensor data: routine cluster analysis. JMIR Mhealth Uhealth. 2022;10(4):e31006. doi:10.2196/31006

4.?Hung YY, Chan HY, Pan YJ. Risk factors for readmission in schizophrenia patients following involuntary admission. PLoS One. 2017;12(10):e0186768. doi:10.1371/journal.pone.0186768

5.?Brissos S, Veguilla MR, Taylor D, et al. The role of long-acting injectable antipsychotics in schizophrenia: a critical appraisal.?Ther Adv Pyschopharmacol. 2014;4(5):198-219. doi:10.1177/2045125314540297

6.?Park EJ, Amatya S, Kim MS, et al. Long-acting injectable formulations of antipsychotic drugs for the treatment of schizophrenia. Arch Pharm Res. 2013;36(6):651–659. doi:10.1007/s12272-013-0105-7

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