Approach Considerations
Treatment of schizophrenia requires integration of medical, psychological, and psychosocial inputs. The bulk of care occurs in an outpatient setting and probably is best carried out by a multidisciplinary team, including some combination of the following: a psychopharmacologist, a counselor or therapist, a social worker, a nurse, a vocational counselor, and a case manager. Clinical pharmacists and internists can be valuable members of the team.
It is important not to neglect the medical care of the person with schizophrenia. Obesity, diabetes, cardiovascular disease, and lung diseases are prevalent in schizophrenia, and the person with schizophrenia often does not receive adequate medical care for such conditions.[78]
Antipsychotic medications (also known as neuroleptic medications or major tranquilizers) diminish the positive symptoms of schizophrenia and prevent relapses. Approximately 80% of patients relapse within 1 year if antipsychotic medications are stopped, whereas only 20% relapse if treated. Children, pregnant or breastfeeding women, and elderly patients present special challenges. In all of these cases, medications must be used with particular caution.
The choice of which drug to use for treatment of a patient with schizophrenia depends on many issues, including effectiveness, cost, side-effect burden, method of delivery, availability, and tolerability. Many studies have compared antipsychotic drugs with one another, but no broad consensus has been reached. In the absence of clinical or pharmacogenetic predictors of treatment response, the current treatment approach is largely one of trial and error across sequential medication choices.
Although treatment is primarily provided on an outpatient basis, patients with schizophrenia may require hospitalization for exacerbation of symptoms caused by noncompliance with pharmacotherapy, substance abuse, adverse effects or toxicity of medications, medical illness, psychosocial stress, or the waxing and waning of the illness itself. Hospitalizations are usually brief and are typically oriented towards crisis management or symptom stabilization.
Treatment of patients with schizophrenia, particularly during a psychotic episode, may raise the issue of informed consent. Consent is a legal term and should be used with respect to specific tasks. A person who is delusional in some but not all areas of life may still have the capacity to make medical and financial decisions.
Insurance concerns
In the United States, patients with schizophrenia who are unable to work may be eligible for governmental programs, such as Medicare and Medicaid. These programs pay the cost of medical care. Unfortunately, if individuals begin to work and earn a sufficient salary, they may lose these benefits—an especially problematic occurrence when, as is often the case, their job provides minimal or no health benefits. This situation is complicated and must be monitored closely by professionals with a good understanding of health benefits.
The impact of the American Affordable Care Act (ACA) on the care of schizophrenia has yet to be determined. Some parts of the ACA, such as the removal of exclusion of preexisting conditions as a barrier to getting insurance, and the removal of annual and lifetime benefit limits, will be helpful. The ACA mandates parity between care for medical and psychiatric illnesses.
However, health plans in the new exchanges might not provide all of the services that are mentioned here, such as supported employment. As well, in the states that have chosen not to expand their Medicaid programs, patients with Medicaid as their insurer may continue to have difficulty in accessing care.[#Antipsychotic]