Making Space for Patient Needs When Treating First-Episode Schizophrenia With Dr Jonathan M. Meyer

In this video, Jonathan M. Meyer, MD, Voluntary Clinical Professor of Psychiatry, University of California, San Diego, provides insights on how to account for each patient's unique needs and concerns when treating first-episode schizophrenia. Dr Meyer explains how to frame the benefit of medications around a patient's particular goals as well as how to bring up long-acting injectables (LAIs).

Watch Part Two: Tailoring Treatment to Patient Goals and Providing the Clozapine Option as Standard of Care here!

Read the Transcript:

Dr Jonathan M. Meyer: Hi, this is Dr. Jonathan Meyer, clinical professor of psychiatry at the University of California, San Diego, and psychopharmacology consultant to various state hospital and first-episode psychosis programs here to talk about how to tailor treatment regimens for patients with schizophrenia.

This shouldn't be a surprise, but every patient is different. Their needs and concerns are unique. And our job as clinicians is to try to meet them in the middle, to come to what we say is a shared decision where we feel like we can best meet their needs while also trying to accomplish the goals of treatment. One thing I'll say is that the goals of treatment are not just our goals, meaning symptom reduction, but also the patient's goals. A big part of trying to come to shared decisions and getting patients to buy into what you're trying to do is to really figure out where they are in their journey with the illness.

So let's start with somebody who's in their first episode. They may still be adjusting to the concept that this thing has happened to their brain, this schizophrenia, and maybe their brain doesn't work the way it used to or perhaps they're hoping it will still go back the way it was, and they're not fully accepting of the fact that this diagnosis might be permanent. It's important to spend a lot of time just finding out what their thoughts are about the illness, what they understand, and most importantly, what their concerns are about medication. They may have all sorts of ideas, realistic or not, about medication, or they may not want medication at all. They may be very hostile to the idea that they have to take something once they leave the hospital.

As best you can, try to address their concerns, especially if they revolve around certain types of adverse effects. It's really critical for people who say, "I'm worried about weight gain or sedation," to acknowledge this and say, "Let's try to find an option which minimizes those risks." Also, you have to understand, because they are in their first episode and are often younger, they will be sensitive to a lot of adverse effects, not only sedation and weight gain in particular, but also endocrine adverse effects and motor adverse effects. A big part of our job is educating the patient that they may be very sensitive to certain things, and we'd like to try to find a regimen that'll best suit their needs.

Importantly, people in their first episode don't know about the existence of long-acting injectables (LAIs). Given the fact that first-episode patients are as nonadherent as any schizophrenia patient, it's really important to have this conversation about LAIs. Present them as convenience, as a benefit, as a way of getting treatment that'll keep them stable, and also will eliminate that daily reminder that they have an illness. This may be particularly helpful for those who are not fully accepting of the illness, for those who are cognitively quite impaired because of their symptoms and may have trouble with daily oral adherence, or for patients for whom there's been a pattern of battles within the family about pill taking. Getting injection gets people out of that loop completely. They get their shot, they go about their business. No one's asking them on a daily basis, "Did you take your medicine?" There's no fights. Also again, for many people in the first episode, there's no daily reminder of their illness.

For people who are further along in their journey who may have had relapses, the question is really, have they been a medication responder, and if they have been a responder, why do they keep relapsing? A big component in relapse, of course, is simply non-adherence, but the question is why. Adverse effects are often a big driver of medication nonadherence, and it's really crucial that you are systematic in going through a list of adverse effects and trying to find out what is it that they really don't like. Was it the weight gain? Was it the sedation? Was it the tremor? Was it restlessness? Was it endocrine adverse effects? Whatever it is, find that out and try to find medication solutions to this problem.

Again, ideally it would be nice if the medication was also available in an LAI form, but at some point you may have to choose a medication which is only available in an oral form as a way of trying to get around some of the prior issues the patient may have had with medication and adverse effects. If the issue has simply been one of nonadherence due to substance use or due to cognitive dysfunction, well, LAIs are probably going to be the solution for that. Again, learn how to talk about these agents as a benefit, not as a punishment, as something which will help them maybe achieve their goals.

This is Dr. Jonathan Meyer. Thank you very much.

Jonathan M. Meyer, MD, is a Voluntary Clinical Professor of Psychiatry at University of California, San Diego, and a Distinguished Life Fellow of the American Psychiatric Association. Dr. Meyer is a graduate of Stanford University and Harvard Medical School, finished his adult psychiatry residency at LA County-USC Medical Center and completed fellowships there in Consultation/Liaison Psychiatry and Psychopharmacology Research. Dr. Meyer has teaching duties at UC San Diego and the Balboa Naval Medical Center in San Diego, and is a psychopharmacology consultant to the California Department of State Hospitals, and to the first episode psychosis programs at Balboa Naval Medical Center in San Diego and in the State of Nevada.

Dr. Meyer has lectured and published extensively on psychopharmacology, and is the sole author of the chapter on the "Pharmacotherapy of Psychosis and Mania" for the last 3 editions of Goodman & Gilman's The Pharmacological Basis of Therapeutics. Along with Dr. Stephen Stahl he is co-author of the Clozapine Handbook published by Cambridge University Press in May 2019, and The Clinical Use of Antipsychotic Plasma Levels released in September 2021 by Cambridge University Press.