APA: Objective Monitoring of Schizophrenic Patients Doesn't Measure Up

SAN DIEGO, May 20 -- Psychiatrists need to do more objective measurement of the physical and mental health of their schizophrenic patients, researchers said here.

Psychiatrists have been relying on clinical judgment, doing minimal medical record-keeping, and sometimes haphazard monitoring of physical consequences of antipsychotic medication for schizophrenic patients, according to a panel of speakers at an industry-funded satellite symposium here held in conjunction with the American Psychiatric Association.

That needs to change, both for the health of patients and to get ahead of pay-for-performance trends, said John M. Kane, M.D., of the Albert Einstein College of Medicine in New York.

Measuring schizophrenia symptoms objectively using rating scales can contribute to diagnosis and help psychiatrists evaluate treatment efficacy as well as tolerability, Dr. Kane said.

"People often utilize a medication that has failed in the past because of inadequate documentation," he noted.

The Clinical Global Impression scale-which rates symptom improvement as "minimally better," "much better," and the like-is most akin to what most psychiatrists already do clinically, he said.

He cited two studies published in 2005 in Schizophrenia Research and the British Journal of Psychiatry, respectively, noting that they found a nearly linear correlation between the Clinical Global Impression scale ratings and those on the Positive and Negative Syndrome Scale (PANSS), which is typically used in clinical studies.

One of the studies showed that the 20% improvement used as response criteria in most schizophrenia clinical trials corresponds to "minimal" improvement on the Clinical Global Impression scale.

"That's not what you're looking for as a clinician," Dr. Kane said, "and I would argue that is not appropriate."

Remission is a better target, he said. On the PANSS scale, it has been defined as no greater than mild (a score of three) rating on all eight symptom items, including delusions, mannerisms and posturing, and conceptual disorganization, for at least six months.

"Measurement-based clinical decision-making is critical and feasible," Dr. Kane concluded.

One important use of rating scales in schizophrenia is in measuring aggression, said Michael H. Allen, M.D., of the University of Colorado Health Sciences Center in Denver.

The PANSS-Excited Component scale is increasingly used to measure agitation, he noted. Although not developed specifically for this purpose, it has the advantage of requiring only observation rather than interaction with the patient.

He also noted that involuntary intramuscular injections dropped 23% at one hospital when a measurement protocol was instituted, citing a study published in the journal General Hospital Psychiatry in 2006.

A main barrier to use of such scales has been the perception that doing so takes too much time, Dr. Kane said.

That's been the case with measurement of cognitive dysfunction, one of the core features of schizophrenia, said Rona J. Hu, M.D., of Stanford University.

Historically, cognitive testing would last for hours or even days. "And, that could be called assault and battery," she quipped.

However, the 2004 National Institute of Mental Health-funded MATRICS (Measurement and Treatment Research to Improve Cognition in Schizophrenia) study established a standard battery of cognitive tests lasting only about an hour and requiring little more than pencil and paper.

In addition to better mental health measurements, schizophrenia patients need more consistent attention to their physical health, said Stephen R. Marder, M.D., of the University of California, Los Angeles.

These patients are at 50% higher risk of death from medical causes -- primarily heart disease -- and have a 20% shorter lifespan than individuals without schizophrenia, he noted.

Atypical antipsychotic medication in particular contributes to weight gain and changes in glucose, cholesterol, and triglyceride levels, all of which affect heart disease risk.

"I think we should take some responsibility for reducing this risk," Dr. Marder said.

Currently, monitoring of physical health is highly variable depending on the setting where care is managed, he said.

"Patients may have very limited access to primary care providers," he noted, adding that, in any case, primary care physicians "may not be aware of the risks associated with psychiatric illness."

But if monitoring physical health does fall to psychiatrists, Dr. Marder said, the situation is complicated by the fact that psychiatrists often lack even the basic tools, such as a scale and blood pressure cuff.

And, "psychiatrists may be reluctant to monitor medical problems when they are uncomfortable intervening," he said.

An informal survey of the audience confirmed that: 65% were uncomfortable initiating a lipid-lowering drug.

According to guidelines developed at a Mt. Sinai conference that Dr. Marder led, weight and blood pressure monitoring are the most important things for psychiatrists to keep track of. Patients and their caregivers can measure these at home, he said.

Dr. Kane concluded that the practical tools and skills discussed in the session are likely to grow in importance in schizophrenia care.

"I think we are going to be seeing more and more of this," Dr. Kane said. "Further guidelines should be developed to facilitate implementation."