Challenges for the Treatment of Schizophrenia
MAY 21, 2020
John M. Kane, MD: The differential diagnosis for schizophrenia is a challenge because there are many medical illnesses that can [resemble] psychosis. Many people are abusing substances that can produce psychotic reactions. The differential diagnosis is difficult at times, but the DSM [Diagnostic and Statistical Manual of Mental Disorders] criteria that we use are reliable and valid.
For uncomplicated cases, it is not that difficult for a psychiatrist to make a diagnosis of schizophrenia. It’s important to have a longitudinal perspective to understand the course of the person’s signs and symptoms, to make sure that it wasn’t just a transient episode of hallucinations or unusual thoughts but that it has been persistent and has affected the person’s functioning. Then we can be confident that we are dealing with schizophrenia. I recommend we maintain a longitudinal perspective and that we’re constantly reevaluating the diagnosis to make sure it’s right.
My preference would be that a specialist makes the initial diagnosis of schizophrenia and implements treatment. Subsequently, it could be taken over by a family physician or a general practitioner, but they are not necessarily trained to make a diagnosis. It’s a challenge to elicit the psychotic signs and symptoms and understand their course and their impact. I know there are some situations where a psychiatrist might not be available to provide that initial evaluation, but when a person with that specialty is available, it’s preferable that they at least make the diagnosis, start the treatment, and then provide recommendations to the general practitioner or family physician.
There are many unmet needs and challenges when we treat patients with schizophrenia. It’s an illness that can affect judgment and insight, and sometimes people do not understand the fact that they are ill. They don’t accept treatment. That can be a real challenge, and families often struggle with that. We also have effective treatments, so the medicines that we call antipsychotic medicines can be highly efficacious in alleviating the acute signs and symptoms of schizophrenia and also in reducing the risk of relapse, but they don’t have as much of an impact on the negative symptoms and the cognitive dysfunction that patients with schizophrenia can experience. Those symptoms can contribute to the functional disability that patients struggle with. An important unmet need is to develop better treatments for those domains: cognition and negative symptoms.
In addition, we do have some patients who don’t respond adequately in terms of the positive symptoms. A proportion of people are what we call treatment resistant even from the very outset of the illness, and we need better treatments to offer those patients.
Transcript Edited for Clarity