7-point checkup: Defuse cardiovascular and psychiatric risks in schizophrenia outpatients

4. Eps and tardive dyskinesia

Compared with FGAs, SGAs may be associated with a lower incidence of tardive dyskinesia (TD) and extrapyramidal symptoms (EPS). Even so, routine screening for EPS and TD remains necessary, according to the Mount Sinai consensus conference on physical health monitoring of patients with schizophrenia.¹⁶ At every visit, we observe Mr. K for:

• facial movements (excessive blinking, puckering, lip smacking, sucking, or grimacing)
  
• decreased arm swing while walking or choreoathetoid-like or writhing limb or trunk movements.
  

We also ask him about subjective feelings of rigidity, restlessness, or changes in voluntary or involuntary movements. Every 6 months we do a more thorough assessment—such as the Assessment for Involuntary Movement Scale—regardless of the antipsychotic he is taking. We test his limbs for rigidity or cogwheeling, observe him for changes in arm swing and gait, and check his mouth for tongue fasciculations. Patients at higher risk for TD, such as the elderly, should be examined more often.

In addition to screening for metabolic syndrome, EPS, and movement disorders, the Mount Sinai consensus conference¹⁶ offers guidelines for monitoring prolactin, cardiac, and ocular changes in patients taking antipsychotics.

5. Mood disorders, substance abuse

Screen schizophrenia outpatients for signs of anxiety, depression, mania, and substance abuse at every visit. An antidepressant trial is recommended for depressive episodes even if antipsychotic therapy has adequately reduced positive psychotic symptoms.¹⁷ This strategy can prevent depressive relapses and might help prevent psychotic relapse as well.¹⁸ Also consider adjunctive therapy such as:

• mood stabilizers for affective instability
  
• benzodiazepines for short-term anxiety or agitation
  
• tricyclics or selective serotonin reuptake inhibitors for comorbid anxiety disorders such as obsessive-compulsive or panic disorder.¹⁹
  

As part of Mr. K’s routine mental status exam, we ask him about his mood, sleep, appetite, energy, anxiety level, and thoughts of hurting himself or others. If mood symptoms are present, we question him further to determine if he meets criteria for a coexisting affective illness.

Because of Mr. K’s history of marijuana abuse, we tell him we will use random urine toxicology screens. We also order urine toxicology if patients behave abnormally or appear impaired. We counsel patients and families about the link between substance use and psychotic decompensation, which Mr. K has demonstrated several times.

We emphasize that the goal of repeated questioning and screening is to ensure Mr. K’s well-being. If he is using substances, we will refer him to the help he needs.

6. Prodromal signs of relapse

Mr. K has reported decreased sleep, increased irritability, increased social isolation, and some agitation before his acute psychotic decompensations. These symptoms form his prodrome for relapse, which we routinely assess at follow-up visits.

We question him about sleep, social contacts, irritability, and agitation; assess psychotic symptoms; and observe thought processes and behaviors. If a patient endorses or displays prodromal signs of relapse, we consider:

• Is he taking the medication?
  
• Is he abusing substances?
  
• Does a change in dosage (actual or a cytochrome P450-mediated drug-drug interaction) explain a decrease in efficacy?
  
• Is he under stress and need an increased antipsychotic dosage?
  
• Might psychosocial interventions (support groups, cognitive-behavioral therapy, family involvement, etc.) help him deal with symptoms, decrease stress, or avoid an exacerbation?
  
• Has medication been optimized (correct dosing, long enough duration), or does the patient need an increased dosage or a different antipsychotic?
  

When we detect prodromal symptoms, we see patients more often (every 1 to 2 weeks) until interventions can be tried and patients are stable again. Detecting and addressing prodromal symptoms early may help avoid hospitalization and minimize potential consequences of relapse.

7. Psychosocial interventions

Combining medications with psychosocial programs is most effective for maintaining remission and improving patients’ social and occupational functioning.¹⁷ For Mr. K we recommend these interventions:

Social skills training. Mr. K now meets with other schizophrenia patients and a moderator to set long-term goals and smaller, attainable goals as homework assignments each week. Patients get feedback, positive reinforcement, and the opportunity to practice new skills. Mr. K is working on improving family relationships, furthering his career, and improving his interpersonal skills.

Family therapy and education. We have met with Mr. K’s mother several times, and she now visits him regularly and speaks with him on the phone at least once a week. She attends Support and Family Education and National Alliance on Mental Illness meetings to increase her understanding of her son’s illness.

Alcoholics Anonymous/Marijuana Anonymous. We refer Mr. K to AA/MA groups; he attends 2 to 3 times per week and has a sponsor. He is not sober yet but has dramatically cut back his substance use and continues to express motivation to quit.