John J. Miller, MD: Dr [Caroline] Carney, which factors do you consider when working with a patient to select an antipsychotic to use to treat schizophrenia? And how do current guidelines need to be updated to help address other elements beyond medications and treating schizophrenia?

Caroline P. Carney, MD, MSc, FAPA, FAPM, CPHQ: That’s a terrific question. I start by looking at the patient who is in front of me. And the first question is, is this a person who is in acute crisis and we have symptoms that we must treat right away because they are a danger to themselves or others, or their disconnect with reality is so severe at that point that they can’t engage in their own decision-making at that time to have truly informed consent? Is this person in that type of setting, or is this person in a chronic setting and they’re coming because they’re a new patient to me, for instance, and we need to look at them holistically? The second factor I keep in mind is, what does that patient want? What are their goals? To Sandy’s point, what does recovery mean for that individual? What symptoms are we treating? Are we treating only positive? Are we treating positive, negative, and cognitive? What are that person’s goals? Third is to ensure that they understand the pros and cons of all the treatment options in front of them to truly be able to give informed consent. When I set aside those, I start evaluating the patient to understand a variety of factors, including [whether] they have been on medications before and [whether] there are medications or groups of medications that help. If they have and have failed, a word that I don’t like to use—the medications fail individuals, individuals don’t fail—we have to understand whether there was an adequate trial of that medication at an adequate dose and duration of treatment to know, vs did they have so many adverse effects that the medicine just wasn’t tolerable, leading them to sleep all day, as Sandy described. Next, I consider the comorbid health factors. While there is a tendency today to use second-generation antipsychotics as first-line therapy and medication, those come with a myriad of adverse effects that can complicate underlying metabolic disease or cause metabolic disease, complicate cardiovascular disease, including hyperlipidemia, and downstream poor outcomes because of those. Does that individual have the ability to take medication every day? Are they organized enough in their ADLs [activities of daily living] to be able to do that? So, [I look at] different factors with that individual, including their health factors, their health risk factors, and their ADLs in terms of their cognitive functioning and their organization to be able to take medication. I also look at, again, what that individual is seeking in terms of their longer-term goals. Do they want to be medicated chronically? Do they want to take medication? In a stable patient who we know a medication has worked and there is an equivalent long-acting injectable antipsychotic, can I use that instead? And [for] a person who is less inclined to have adherence for that variety of reasons, is a long-acting injectable the more prudent course for them because it will keep those positive symptoms under control in a better period of time? There are also complications of the drugs that we have to do a fuller medical workup for, including laboratory assessments of electrolytes, liver function tests, so on and so on, including an EKG [electrocardiogram], because many of these medications can cause a change that is a fatal change in their rhythm. They cause something called a QTc prolongation, and we can see that in an EKG that needs to be monitored over time. And then finally with regard to all of this, [in] monitoring that person, did that person have adequate serum levels of the medication? Do we know they’re taking the medication? Those factors are related to adherence, and is that drug working? In my own clinical practice when I know that individuals have had an adequate dose or duration and they seem not to be responding, I don’t hesitate to use pharmacogenomic testing to understand if that person [is] able to metabolize the medication that they’re using. Is there a drug-drug interaction with something else that they’re on perhaps for a medical condition? Is the medication being metabolized in a way that I think will due to that drug-drug interaction? Or have I just missed the boat altogether and that person will have no response and we really need to change what we’re doing in therapy? I can tell you of incredible changes in course with the results of testing like that helps to guide. One last thing I would say, not related to the testing itself, but in terms of diagnosis as a med psych doctor, I have paid attention very closely to the onset of symptoms, and the onset of symptoms outside of the typical descriptions of earlier onset, late teens, 20s, and so on. When I see someone in their 40s, 50s, or 60s, presenting for the first time with psychotic symptoms, I always do a medical workup alongside that first.

John J. Miller, MD: Thank you.

Transcript edited for clarity.