Transition of Patient Care Protocols in Schizophrenia


Henry Nasrallah, MD, discusses optimal protocol for patients with schizophrenia transitioning from a hospital to an institutional setting, along with discharging from the institutional setting and highlighting the importance of physician continuity with outpatient care.

Henry Nasrallah, MD: Well, we usually do not transfer patients from the inpatient acute hospitalization to another institution unless they are very chronic already, they go back to their board and care home or group home, as sometimes it's called. Or we discharge them to an outpatient community mental health center for follow-up. Now that's where sometimes things can get dicey. If the patient is discharged on an injectable that—with the agreement of the treatment team on the inpatient unit, there's no guarantee that the community mental health center psychiatrist or nurse practitioner is going to continue that. I've seen it again and again. They switch them back to oral, whichever their favorite oral medication is. That's a problem. It really is. Because they discontinue with your healthcare. 

When you move from one treatment team to another treatment team things fall between the cracks. The other treatment team does not always continue the same treatment plan that was initiated at the hospital. So that's a big problem. That's why I believe in continuity of care. The ideal way to treat patients with schizophrenia is to continue following them up yourself after discharge from the hospital rather than sending them to some unknown physician or nurse practitioner somewhere to take care of them. 

I know it's hard logistically for many people to do that. But that's the ideal way to treat patients. Otherwise, the treatment is going to be discontinued or changed and there's no guar-antee the patient is going to take the medication or even respond to another medication. Switching from one antipsychotic to another does not always mean that they're going to continue responding. The side effect profile might be different. Tolerability may be different. So good treatment of seriously mentally ill patients really requires not just intensive inpatient care but also continuity of outpatient care. That's the guarantee that I want to see for most of our patients to protect them from the horrible outcomes that occur when patients relapse again and again.

The first episode patients are still with their families. Many times we discharge them home to their family home. They live with their family. Those—this is where the family burden can also be decreased by giving long acting injectables. Because if we discharge them on oral medication and we tell them, the parents, how serious it is if they relapse, friction develops sometimes because the patient honestly forgets to take the pill and the parents bug the patient, you know, you forgot your pill, did you take you pill. 

They're kind of on their case and that irritates the patient. So you can get some tension inside the family when the patient is discharged home and the parents are in charge of making sure they're taking the oral if you don't give an injectable and they take oral. It's not a smooth transition many times. The patients—the parents will feel very guilty if the patient relapses and comes back to the hospital. They blame themselves and it becomes like a serious blow and trauma to the mental health of the family.

Transcript Edited for Clarity

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