Opinion
Video
Barriers to Appropriate Care for Patients Diagnosed with Schizophrenia
Sandy Dimiterchik, an advocate for patients diagnosed with schizophrenia, leads the panel in a discussion highlighting barriers that inhibit optimal patient care.
John J. Miller, MD:Sandy, what do you see as some of the significant barriers to the coordination of care for patients with schizophrenia in terms of [managing] the negative and cognitive symptoms once the positive symptoms have been reasonably stabilized?
Sandy Dimiterchik: As you probably know, research shows that people with schizophrenia typically die 25 years younger than the rest of the population. And a lot is going on there. I know we do [have] free support groups [such as] Schizophrenia & Psychosis Action Alliance. So I’ve heard from people about their experiences. And even though the positive [symptoms] might be [managed], you’re left with the adverse effects of the medication. I hear from people who talk about diabetes, and talk about weight gain [and] being tired all the time. It’s really important to have care coordination, having a primary care doctor there to help you. I [had diabetes], but the doctor had me see a dietician, and I completely changed how I ate. [I] was able to go off the medication, and he said, “I don’t think you [have diabetes] anymore.” So that was powerful, but not everybody has the same experience as me. I’m one of the lucky ones. But for a lot of people, they might only get treated by their psychiatrist and may not see other doctors.
John J. Miller, MD:That’s an excellent point that you raise. Just thinking about some of the patients whom I’ve seen, if the medication they’re on causes sedation, for example, as an adverse effect, that’s going to affect their cognitive functioning and it may make the negative symptoms look worse. Or in terms of the metabolics, if you [have hypoglycemia], you’re going to feel tired. So as you nicely point out, it’s important to broaden the treatment to include primary care and include other specialists when necessary, maybe seeing an endocrinologist for diabetes management. And we need to be mindful of the big picture and the 3 strands of cognitive, negative, and positive symptoms interplay and the varying burdens of different types of medications because they all have different adverse effect profiles and be mindful of how they’re [affecting] the negative, the cognitive symptoms.
Nev Jones, PhD: This is another area of care coordination where we’ve seen a lot of growth and development over the past couple of decades, [with] some of that specifically happening in managed care. And I imagine we will circle back to the managed care section, but [for] behavioral health homes, primary care integration models, and the new SAMHSA [Substance Abuse and Mental Health Services Administration] CMS [Centers for Medicare & Medicaid Services] Certified Community Behavioral Health [Clinic] model, care coordination and integration is fundamental to the model, which is being rolled out across the United States and provides an option for states on the Medicaid side in terms of delivery of services and financing through CMS. So there is a lot of attention on physical health as well. We know that there are significant health comorbidities associated with schizophrenia, and some of that is due to antipsychotics and other medications, strong anticholinergics used in the [management] of schizophrenia. So you see people dying anywhere from 15 to 20 years earlier than Americans [without schizophrenia], developing earlier onset of dementia as well as what’s referred to as early cognitive decline, and cardiometabolic health is seriously [affected as well]. Some of that has to do with these social and structural determinants. People are living in poverty; they don’t necessarily have access to healthy food and exercise. So all that converges to create a perfect storm of poor physical health. And a lot of what is happening right now in the field is intervention strategies and policy to try to mitigate those physical health disparities through stronger coordination models.
John J. Miller, MD:Carlos, let’s circle back to you. What are some of the effects of cognitive impairment on social and behavioral functioning in individuals with schizophrenia?
Carlos Larrauri, APRN: Cognitive impairment in patients with schizophrenia can have a profound impact on their functioning. As we discussed, it’s often the symptom domain that leads to the most functional impairment. For instance, as Dr [Caroline] Carney mentioned earlier, we might see problems with activities of daily living such as cooking, cleaning, and managing finances. For instance, I’ve had patients who were unsure whether they’d left the stove on, and these kinds of impairments can lead to dependence on others for support and care and affect individuals’ abilities to live independently. We could also see trouble with social withdrawal if someone’s cognitive features or impairments make one uncertain of what others are thinking or how to read others’ emotional cues. It may lead to social withdrawal or isolation or avoiding social situations to minimize stress. We may also see employment challenges. We’re increasingly in a service- and information-oriented economy, and that requires managing information, completing tasks efficiently, and making decisions. And if someone struggles with these executive functioning tasks, it could lead to unemployment or underemployment. Treatment adherence is another functional outcome that could be affected by cognitive impairment. Managing a complex chronic condition [such as] schizophrenia can require managing multiple medications or appointments with several specialists. And this can be challenging, and if someone has cognitive impairments, it can affect their ability to manage their overall mental health.
Transcript edited for clarity.
