Communication of treatment duration in schizophrenia

Schizophrenia in the vast majority of cases is a chronic long-term disorder and as such requires long-term, continued treatment. The predominant and recommended treatment for schizophrenia involves the continued long-term use of antipsychotic medication for both symptom control and the prevention of relapse (Wade et al., 2017). Recently, Correll et al. (2018) weighed in on the risk versus benefit debate that has emerged regarding the long-term use of antipsychotic treatment in schizophrenia. After a thorough review, it was noted that there is substantial evidence to support the short- and medium-term efficacy of antipsychotics and there is inadequate evidence to suggest that this efficacious effect changes in the long term. Furthermore, the review indicated that people with schizophrenia treated with antipsychotics have lower mortality rates than those who are not being treated with antipsychotics (Correll et al., 2018).

It should be noted that there are individuals with psychosis who recover without on-going treatment and some who even recover spontaneously without the use of antipsychotics. Although the current evidence weighs on the side of continued long-term treatment, this does not negate the need for further research to delineate individual factors that could predict those who will remain relapse free upon discontinuation of antipsychotic treatment. Correll et al.’s (2018) debate is not about these individuals or individuals with first episode psychosis who tend to have heterogeneous polymorphic presentations with uncertain trajectories; thus, the prognostication and prediction of long-term treatment in first episode psychosis are uncertain. Rather this debate is concerned with individuals who meet the criteria for the diagnosis of schizophrenia of which the greater proportion of these individuals will require on-going treatment.

Continued long-term treatment with antipsychotic medication is known to be related to better clinical and functional outcomes as well as the prevention of relapse (Wade et al., 2017). However, clinical guidelines do not provide systematic recommendations for treatment continuation or discontinuation beyond 1–2 years as the effects of treatment beyond 2 years is not well understood. However, guidelines do warn of the risk of relapse associated with discontinuation (Correll et al., 2018; Galletly et al., 2016).

Although continued long-term antipsychotic treatment is necessary and recommended by clinicians, many individuals with schizophrenia fail to adhere to treatment. Wade et al.’s (2017) research has indicated that between 75% and 90% of individuals discharged from hospital discontinue their medication within a year or two of discharge (Wade et al., 2017). This discontinuation results in relapse, greater functional impairment and a poorer prognosis for the individual. Moreover, nonadherence to antipsychotic treatment has a myriad of individual-, familial- and societal-level consequences. Therefore, adherence to the antipsychotic regime prescribed is a primary issue in the treatment of psychotic conditions.

A recent systematic review conducted by Wade et al. (2017) identified a range of themes pertaining to adherence and nonadherence in previous quantitative and qualitative studies. In regards to nonadherence, the most pertinent themes identified were poor efficacy of medication, negative personal beliefs about medication, side effects, influence of significant others including a poor therapeutic alliance, stigma and financial issues (Wade et al., 2017). In regard to medication beliefs, one of the factors identified was the belief that medication was no longer required once symptoms abated (Wade et al., 2017). Thus, the question arises as whether the duration of treatment is explicitly and effectively communicated by the prescribing clinician to the patient when a diagnosis of schizophrenia is established?

Within a chronic disease model, evidence exists that appropriate communication of the need for long-term, indefinite treatment increases treatment adherence. However, within psychiatry, clinicians appear to be hesitant to explicitly state the need for long-term and probable indefinite antipsychotic treatment for schizophrenia. This reluctance is thought to result from not wanting to impede the hope of their patients and is probably further exacerbated by the young age of the patient and their vulnerable state at the time of diagnosis, as the onset of schizophrenia predominantly occurs during adolescence and early adulthood.

However, clear evidence exists for the need for long-term and probable indefinite treatment to manage such conditions, and it is imperative that this information although distressing be conveyed at the initiation of treatment, as well as being reiterated particularly for patients who were too ill at the time of treatment initiation to comprehend the information they were being given. Thus, is treatment duration explicitly and effectively communicated to patients or is the issue being ‘tiptoed around’ or merely implied? The need for continuation of treatment needs to be explicitly explained and the implications of discontinuation need to be made clear at the point of diagnosis and if not possible at that point as soon as the psychosis has abated enough that the patient has ability to understand the message and the inherent implications. Discontinuation is a decision and as such patients need to be made aware of the consequences of such decisions.

One of the main issues identified in Wade et al.’s (2017) systematic review was the primary role the therapeutic alliance had on adherence and nonadherence to medication. A strong clinician and patient alliance with open communication is associated with better patient adherence (Thompson and McCabe, 2012). Pivotal to achieving a strong clinician–patient alliance is effective communication. A strong therapeutic alliance is consistently associated with adherence in mental health including in schizophrenia (Thompson and McCabe, 2012). Research has highlighted the importance of shared communication about treatment details generally rather than shared treatment decisions (Thompson and McCabe, 2012).

Similarly, other research has indicated that information about medication has an effect upon adherence. A recent study aimed at assessing the desire for information about their illness by people with a severe mental illness found that 80% of patients wanted to receive information on all aspects of their illness (Giacco et al., 2014). Participants with less severe symptoms and a better clinician–patient alliance had a higher desire for information than those with more severe symptoms and a poorer clinician–patient alliance (Giacco et al., 2014). Thus, in accordance with these findings, the majority of patients want to know about their treatment and prognosis; as such a discussion regarding the duration of treatment and the effects of nonadherence upon prognosis is imperative.

Furthermore, another factor that has been found to be associated with adherence is the belief that biomedical factors as oppose to psychosocial factors are the antecedents to the psychosis (Wade et al., 2017). Whereas if individuals endorse a psychosocial cause for their illness, the long-term use of antipsychotics tends to be perceived as unnecessary as opposed to when a biological view is held (Wade et al., 2017). This association with biomedical causation is known to increase adherence as it increases the perception that medication is the appropriate form of treatment akin to other general medical conditions. In accordance with the biomedical model, long-term continued use of antipsychotics is the primary recommended treatment for schizophrenia.

Thus, it is apparent that treatment duration needs to be explicitly defined for patients initiating treatment for schizophrenia rather than avoided and implied in order to spare the patient distress. As arguably, the distress avoided at that time point may result in more significant distress at a later time point after nonadherence has resulted in greater functional impairment and poorer clinical prognosis. Furthermore, it is apparent that adherence can be further enhanced through forging a strong therapeutic alliance and promoting a biomedical model of causation.