Rahn Bailey, MD, DFAPA, and Henry Nasrallah, MD, discuss the challenges and unmet needs psychiatrists and their teams face when treating patients with schizophrenia and their multiple comorbidities.
Peter Salgo, MD: Henry, I hear you saying that psychiatrists are best equipped to deal with these issues. Are there enough psychiatrists? Are they distributed around the United States in a way that makes referral feasible for every person with schizophrenia?
Rahn Bailey, MD, DFAPA: Clearly there are not enough psychiatrists with that level of specialization, but that’s exactly why the ideal team approach is essential in all of medicine, but especially in this setting. The high-level training required to treat this level of a brain illness is essential to have a fighting chance of managing the problem, let alone move patients to a level where perhaps they could have full remission of illness. A psychiatrist must be involved in every single patient’s care with regard to schizophrenia.
I think as Henry said very correctly, any individual cannot manage this singularly. The comorbidities are so substantial…. Our patients have more congestive heart failure, diabetes, asthma, and cancer, so it is optimal when there’s a team approach, including a primary care doctor. At Kedren Hospital, here in Los Angeles, we have a nurse practitioner on each team and a consultant primary care doctor with an outpatient primary care site. We’re strengthening our team approach, so we also have a social worker, a psychologist, and occupational therapist, and we strengthen our team approach with the psychiatrist and nurse practitioner as a team doing rounds daily with a consultant primary care doctor. We’ve seen our clinical results on the medical side improving patients, and that’s given them the chance to do better psychiatrically as well. It’s essential that we have a team orientation to manage the complexities of schizophrenia.
Peter Salgo, MD: I’m going to go off on a limb for just a moment because something you said really struck me, which is that your patients with schizophrenia have more comorbidities than the population at large, whether it’s arthritis, diabetes, and/or heart failure. I immediately ask why? Are they located on some allele, that they’re co-located, or is this that they’re not getting engaged in the health care system? What’s going on here?
Henry Nasrallah, MD: Patients with schizophrenia have medical conditions at the onset of their illness, before we ever treat them with any antipsychotics that are supposed to increase their metabolic dysregulation, etc. There are massive studies done showing that even at age 18 or 20, first-episode patients have multiple medical conditions that lead to hospitalization, medical hospitalization, emergency department visits, health care utilization, and we attribute that at this point to the immune dysfunction in schizophrenia. When you look at the genetics of patients with schizophrenia done with gene-wide association studies, the strongest difference between patients with schizophrenia and the general population, in addition to 400 susceptibility genes for schizophrenia, the histocompatibility complex, the immune regulating part of the body, is very abnormal in schizophrenia. That accounts for why they are vulnerable to so many medical conditions.
Peter Salgo, MD: Of course, this begs the question, if patients with early schizophrenia present with lots of other morbidities that are associated with a metabolic disarray, it behooves the practitioner seeing them to be on the lookout for, lack of a better phrase, pre-schizophrenic symptoms. If you’re seeing somebody who is very young, atypically young for 1 of these co-located problems, should that ring an alarm bell and you say, “Maybe there’s something else going on here?”
Rahn Bailey, MD, DFAPA: By definition, 1 of the historical adversities for our patients, a reason why they’ve been more medically ill and dying earlier, early mortality of medical concerns, has been the misappropriation and consideration that if you have a primary psychiatric problem, that it’s “all in your head.” Primary care doctors and doctors who are not psychiatrists have disproportionately been less inclined to engage in more descriptive work, diagnostic techniques, and the like for outpatients, when they should have been more engaged in that activity in this patient population.
We know so much more now about how inflammation seems to be at the underpinning of so much of the disease process, from a medical side and psychiatric. Clearly, our patients have more psychiatric difficulty, which we now think is a heterogeneous group of disorders, cognitive and psychotic and emotional, so it’s likely that you’re going to have a lot of carryover there as part of the problem.
Peter Salgo, MD: What I’m hearing from you is that there’s a lot of bias against psychiatric illness and that it persists in the health care delivery system. It certainly was there when I was an intern; it’s still there now, isn’t it?
Henry Nasrallah, MD: You mentioned earlier, Peter, about early recognition, what you call the prodrome, before the onset of the first episode. Yes, some of those young people are going to see a primary care physician. But I really think we should educate the families. The families are woefully unaware in general. The general population has no idea what the prodromal symptoms are, and they think this is just like regular adolescent behavior, lability, and odd behavior. We need to educate the public about the earliest warning signs of impending psychosis because the teenagers and high school and college years are the population at risk. This is the most likely period to start a psychotic episode, as well as bipolar, substance use, eating disorders, and depression. They tend to occur during adolescence and the early 20s. We need to educate the public at large about this fact and about early recognition so they can refer them for care as soon as possible.
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Transcript Edited for Clarity