Schizophrenia: The Risk and Impact of Recurrence

OCTOBER 15, 2019
HCPLive Network

Peter L. Salgo, MD: If you don’t take your diabetes medicine, you run the risk of hyperglycemia, DKA [diabetic ketoacidosis], and all the known physiological consequences. If you don’t take your antipsychotic medicine, what’s relapse like?

John M. Kane, MD: If you don’t take your antipsychotic medicine, you run the risk of relapse. What happens in a relapse is that you’re going to have a recurrence or an exacerbation of your original symptoms. Let’s say you had delusions that the mafia was after you or something like that, and you’re afraid to leave your home. Or let’s say you are hearing voices all the time of a voice saying you’re terrible, you’re a failure, you’re awful, and you should kill yourself. Those symptoms can come back again if you relapse. That can lead to another hospitalization and then a complete disruption in social and vocational adjustment. If someone has been doing OK, but they have a relapse, and they get rehospitalized, there’s a chance they’re going to lose a lot of the gains that they’ve worked so hard to achieve.

Peter L. Salgo, MD: Also, if you’re employed and you’ve been gainfully employed—correct me if that’s not what you were alluding to—suddenly your coworkers, your boss, and everybody knows. Whoops, this isn’t done.

John M. Kane, MD: That’s right.

Peter L. Salgo, MD: This is still there, and he’s taking medications for it. It’s not cured. It’s simply treated.

John M. Kane, MD: That’s right.

Peter L. Salgo, MD: That’s a problem.

John M. Kane, MD: That can lead to very obviously, very difficult consequences. If you think about it, we’re very focused on trying to treat people as well as possible early in the course of the illness because we think that’s where we can have the biggest impact. You think about a young person who’s experienced the onset of schizophrenia at the age of 20. Maybe they’re in college or university, and they’re hospitalized. They have to drop out of school for a while. But they respond well to treatment, and they go back to school. If they get sick again, then they have to drop out of school a second time. You mentioned a job. Let’s say you have a good job, your boss is understanding, and he or she takes you back after you recover—after you get over some of the initial symptoms—but then it happens again. Are you going to get the job back? Are you going to be able to get back to work a second time?

Peter L. Salgo, MD: Right.

John M. Kane, MD: You see, even friends. Some of your friends see you in a psychotic state. It can be a little off-putting, but they stick by you. But then it happens again and again, and what I’m saying is you can see some of life’s opportunities being eroded if people have multiple relapses.

Peter L. Salgo, MD: It sounds to me as if part of the problem with effective antipsychotic medication is the same as part of the problem with antihypertensive medicine. The number of people who tell me “I used to have high blood pressure, but now I take medicine, so my high blood pressure is gone,” is probably close to the number of people who say, “I have schizophrenia, I’m taking my medications, and I’m fine.” The antihypertensives get stopped. They get 5 normal blood pressures in a row, and the patient says, “I’m cured.” I’ll bet it’s the same with the schizophrenics.

John M. Kane, MD: It’s similar. I wish that our medicines worked as well as some of the antihypertensive drugs. We’re not quite there yet. With antihypertensive drugs, we have several different mechanisms that we can draw on. With schizophrenia we’re still very much working with the dopamine receptor antagonists, so we’re a little more limited. But you’re absolutely right. I think what happens with many people is “OK, I’ve been feeling well. I don’t need the medicine anymore.” Then the person stops the medicine, comes into the doctor, and says, “Gee, you always told me that if I stop my medicine I’m going to get sick again, but actually I feel fine. I stopped my medicine a month ago.” The reality is even if you stop your medicine completely, it doesn’t mean you’re going to relapse right away. It might be 6 months. It might be 9 months. It might be a year. But the data and the evidence are very clear that the risk is considerable, and the risk is considerably greater when you stop your medicine than if you continue it.

Peter L. Salgo, MD: You haven’t cured the disease.

John M. Kane, MD: Right, exactly.

Peter L. Salgo, MD: It’s still there.

Transcript edited for clarity.

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