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Schizophrenia - Disease Management

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Relapse as a result of suboptimal drug adherence is a major challenge among patients living with schizophrenia

Episodes of relapse are common among patients living with schizophrenia and are often related to suboptimal adherence to antipsychotic medication.1–3 Read the article below to learn more about schizophrenia disease management and the consequences of relapse.

Schizophrenia is a chronic and debilitating mental health disorder that requires long-term sustainable treatment and patient care.1 People with schizophrenia experience episodes of symptom remission and relapse throughout their lives.1 This unstable course of disease affects the patient’s social and occupational functioning, quality of life, and ability to live independently.1 Relapse caused by poor adherence to antipsychotic (AP) treatment is a major concern in patients with schizophrenia as it can lead to rehospitalization, related healthcare costs, productivity losses, substance abuse, violence, and suicide.1,2,4

Poor patient insight is associated with nonadherence to schizophrenia treatment

A patient’s ability to acknowledge their illness and willingly engage in treatment is known as their insight.5 Impaired insight, or anosognosia, has been identified as a primary contributor to AP treatment nonadherence in patients with schizophrenia and can reduce their quality of life and affect their social and work relationships.5 

As insight is difficult to measure in patients with schizophrenia, several tools have been developed to aid these assessments. The G12 item of the Positive and Negative Syndrome Scale (PANSS) rates levels of both patient insight and judgment,5,6 while the Schedule for the Assessment of Insight examines a patient’s recognition of their mental disorder and its symptoms, and their willingness to accept treatment.5 In a study where the PANSS item G12 was used to assess insight, impaired insight was linked to AP medication nonadherence.7 However, adherence to oral medication is inherently difficult for all individuals no matter the medical condition, and often reflects the inconvenience of taking pills daily.8 

It is important to regularly monitor treatment adherence 

Around half of patients living with schizophrenia are nonadherent to their treatment.3 The development and implementation of strategies to regularly monitor and improve long-term adherence to AP medication is crucial to prevent patients from relapsing and improve their quality of life.9 Measuring adherence through self-reported data is often unreliable and more accurate methods are required to fully understand the patient’s level of adherence to treatment.9 

Earlier strategies to assess drug adherence include:9
- Biological markers 
- Clinician examination and rating 
- Pill counting 

These strategies rely on a patient’s willingness to divulge true information regarding their adherence and the clinician’s ability to correctly estimate nonadherence.9 To address these limitations, the Medical Event Monitoring System (MEMS®) was developed as an objective measure of nonadherence.9 MEMS® is an electronic monitoring device comprising a medication bottle cap that is fitted with a microprocessor to track the occurrence and time of each bottle opening.9 When compared with the above methods, MEMS® was found to record a much higher rate of nonadherence to APs.9 The ability of clinicians to correctly predict adherence is limited and adherence is often overestimated.9 In one study, clinicians rated 42% of participants as adherent that were rated as nonadherent by MEMS®.9 Further, 44% of participants rated as nonadherent by clinicians were in fact adherent according to MEMS®.9

Poor adherence to AP treatment is linked to adverse patient outcomes

Compliance to AP treatment is key to preventing relapse.3 Patients who do not adhere to their treatment plan have 100% higher risk of relapse and a shorter time to relapse.10,11 Compared with patients who adhere to their medication, those who are partially adherent (medication possession ratio greater than or equal to 60% but lower than 80%) also have higher rates of hospitalization and longer hospital stays.3 Additionally, nonadherent patients are treated more frequently each year, have lower functioning scores, are more likely to have a major psychotic relapse with less chance of recovery, and are more likely to attempt suicide, compared with adherent patients.12–15 Other factors that have been linked with AP noncompliance include substance abuse and lack of support from family and caregivers.16

Relapse has a major burden on the patient, their families, and society as a whole

An episode of relapse often leads to rehospitalization and increased use of healthcare resources.17 The estimated economic burden of relapse in the US was over $25 million over a three-year period due to psychiatric hospitalization.17 Relapse can also impact a patient’s ability to maintain employment and their productivity.4,18 Moreover, studies have shown that relapse may be related to reduced AP treatment response and subsequent treatment resistance among patients with schizophrenia.18 

Other consequences of relapse include:18 
- Slow and incomplete recovery 
- Progressive cognitive and functional decline
- More frequent suicide attempts
- Psychotic episodes leading to psychological anguish for both the patient and their family 

The societal and economic impact of treating patients with schizophrenia can be reduced by employing disease management strategies to reduce the frequency of relapse in patients.17,18 

References

  1. Biagi E, Capuzzi E, Colmegna F, et al. Long-acting injectable antipsychotics in schizophrenia: literature review and practical perspective, with a focus on aripiprazole once-monthly. Adv Ther 2017;34:1036–48.

  2. Pennington M, McCrone P. The cost of relapse in schizophrenia. Pharmacoeconomics 2017;35:921–36. 

  3. Ascher-Svanum H, Zhu B, Faries DE, Furiak NM, Montgomery W. Medication adherence levels and differential use of mental-health services in the treatment of schizophrenia. BMC Res Notes 2009;2:6.

  4. Jin H, Mosweu I. The societal cost of schizophrenia: a systematic review. Pharmacoeconomics 2017;35:25–42.

  5. Belvederi Murri M, Amore M. The multiple dimensions of insight in schizophrenia-spectrum disorders. Schizophr Bull 2019;45:277–83.

  6. Kay SR, Fiszbein A, Opler LA.  The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull 1987;13:261–76.

  7. Kim J, Ozzoude M, Nakajima S, et al. Insight and medication adherence in schizophrenia: an analysis of the CATIE trial. Neuropharmacology 2020;168:107634.

  8. National Association of Chain Drug Stores: Pharmacies: Improving health, reducing costs. 2011. Available at: http://www.nacds.org/pdfs/pr/2011/PrinciplesOfHealthcare.pdf. Accessed June 2022.

  9. Remington G, Kwon J, Collins A, Laporte D, Mann S, Christensen B. The use of electronic monitoring (MEMS) to evaluate antipsychotic compliance in outpatients with schizophrenia. Schizophr Res 2007;90:229–37.

  10. Csernansky JG, Schuchart EK. Relapse and rehospitalisation rates in patients with schizophrenia: effects of second generation antipsychotics. CNS Drugs 2002;16:473–84.

  11. Pelayo-Terán JM, Galán VGG, Ortiz-García de la Foz V, et al. Rates and predictors of relapse in first-episode non-affective psychosis: a 3-year longitudinal study in a specialized intervention program (PAFIP). Eur Arch Psychiatry Clin Neurosci 2017;267:315–23.

  12. Ahn J, McCombs JS, Jung C, et al. Classifying patients by antipsychotic adherence patterns using latent class analysis: characteristics of nonadherent groups in the California Medicaid (Medi-Cal) program. Value Health 2008;11:48–56.

  13. Dassa D, Boyer L, Benoit M, Bourcet S, Raymondet P, Bottai T. Factors associated with medication non-adherence in patients suffering from schizophrenia: a cross-sectional study in a universal coverage health-care system. Aust N Z J Psychiatry. 2010;44:921–8.

  14. Morken G, Widen JH, Grawe RW. Non-adherence to antipsychotic medication, relapse and rehospitalisation in recent-onset schizophrenia. BMC Psychiatry 2008;8:32.

  15. Novick D, Haro JM, Suarez D, Vieta E, Naber D. Recovery in the outpatient setting: 36-month results from the Schizophrenia Outpatients Health Outcomes (SOHO) study. Schizophr Res 2009;108:223–30.

  16. Olfson M, Mechanic D, Hansell S, Boyer CA, Walkup J, Weiden PJ. Predicting medication noncompliance after hospital discharge among patients with schizophrenia. Psychiatr Serv 2000;51:216–22.

  17. Lin I, Muser E, Munsell M, Benson C, Menzin J. Economic impact of psychiatric relapse and recidivism among adults with schizophrenia recently released from incarceration: a Markov model analysis. J Med Econ 2015;18:219–29.

  18. Kane JM. Treatment strategies to prevent relapse and encourage remission. J Clin Psychiatry 2007;68:27–30.

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