Monitoring

Acute psychotic episodes often require hospitalization. On discharge from the hospital, patients with schizophrenia should have a follow-up appointment with a psychiatrist within 1-2 weeks.

Patients should have a documented, comprehensive, and person-centered treatment plan in place that includes evidence-based nonpharmacologic and pharmacologic treatments.[65]​ A crisis management plan, involving the patient’s family/personal support network and community mental health services is recommended.

Schizophrenia is associated with an increased frequency of physical illnesses. It is also associated with a reduced life span of around 14.5 years compared with the general population, with an average reduction of 15.9 years for men and 13.6 years for women.[92] The net effect of treatment with antipsychotics appears to be a reduction in long-term mortality.[93] However, monitoring and managing the adverse effects of medications used to treat schizophrenia is crucial.

  • Patients should be monitored for the development of extrapyramidal signs (dystonia, akathisia, parkinsonism, and tardive dyskinesia), which are particularly common in patients taking first-generation antipsychotics.[65]​ Assessment with a structured instrument (e.g., the Abnormal Involuntary Movement Scale [AIMS]) is recommended at a minimum of every 6 months in patients with a high risk of tardive dyskinesia and at least every 12 months in other patients.[65][224]​​​

  • Patients with schizophrenia are at increased risk of metabolic problems including obesity, diabetes, hyperlipidemia and hypertension, cardiovascular disease, and premature death. Diabetes, hypertension, and metabolic syndrome are significantly associated with global cognitive impairment in people with schizophrenia, suggesting that metabolic syndrome may contribute to the functional decline experienced by some patients with schizophrenia over time.[229]​​​[230]​

    • Body mass index (BMI), a measure for obesity, should be assessed at baseline and every 4 weeks for the first 12 weeks, then every 3 months thereafter.[65]​ An increase in BMI should prompt consideration of intervention by monitoring weight more closely, engaging the patient in a weight management program, using an adjunctive treatment to reduce weight, or changing the antipsychotic medication.[65]​ Waist circumference, a measure for abdominal obesity, should be assessed annually.[65][231]​​​

    • Fasting blood glucose and lipids should be obtained at baseline and 12 weeks, then annually thereafter.[65][231]​​​

    • Strategies to prevent or mitigate antipsychotic treatment-associated metabolic disturbances include decreasing the dose of antipsychotic medication or switching to a more metabolic neutral medication option. Some studies have suggested that adjunctive treatment with aripiprazole or metformin may counteract such metabolic adverse effects.[232]​[233]​​​

    • Psychosocial interventions should also be considered. A behavioral weight-loss intervention is efficacious in overweight and obese adults with serious mental illness.[234] Health promotion coaching aimed at weight loss and improving cardiovascular fitness is an effective long-term management strategy for patients with schizophrenia.​[235]​ Despite these strategies, patients may still need to be treated with antidiabetic or lipid-lowering medications as required.

    • Effective screening for, and treatment of, hypertension is key. Results of one meta-analysis suggest that people with schizophrenia typically receive poorer care for hypertension (lower rates of screening, prescription, and medication adherence) than people without schizophrenia.[236]

  • Antipsychotic medication with higher dopamine blockade (e.g., haloperidol, fluphenazine, and risperidone) can cause elevated prolactin, leading to galactorrhea, gynecomastia, changes in libido, irregular menstrual cycle or amenorrhea in women, and erectile or ejaculatory dysfunction in men.[65][225]​​ Clinicians should remain alert for these effects and screen for possible symptoms at each clinic visit; prolactin level should be checked if clinically indicated. Decreasing the dose of antipsychotic medication or switching to an alternative medication may be necessary. Limited evidence suggests that adding aripiprazole may have a prolactin-lowering effect.[226]​

  • QT prolongation, T-wave flattening, and torsades de pointes have been reported to occur with antipsychotic use. A baseline ECG may be required, particularly if there are cardiac risk factors such as a personal or family history of cardiac disease (conduction abnormalities and/or structural cardiac abnormalities).[227]

  • Clozapine can decrease the number of neutrophils and may lead to severe neutropenia. In the US, all patients taking clozapine must be enrolled into the Clozapine Risk Evaluation and Mitigation Strategy (REMS) program and be monitored for changes to absolute neutrophil count (ANC) levels. The baseline ANC must be at least 1500/microliter for the general population, and at least 1000/microliter for patients with documented benign ethnic neutropenia (BEN, most commonly seen in individuals of African descent). The monitoring schedule is every week for the first 6 months, every 2 weeks for the following 6 months, and monthly indefinitely thereafter if ANC remains to be at least 1500/microliter (at least 1000/microliter for BEN). If ANC <1500/microliter (<1000/microliter for BEN), the monitoring frequency and the clinical decision regarding the use of clozapine should be adjusted accordingly.[65]​

  • Postural hypotension associated with antipsychotic treatment is dose-related and is usually transitory in the first hours or days of treatment. Older people are particularly vulnerable to postural hypotension, as are patients in the dose-titration phase of clozapine therapy and those with peripheral vascular disease, diabetes with preexisting autonomic neuropathy, or compromised cardiovascular function. When severe, orthostatic hypotension can cause syncope, dizziness, or falls.[65][228]​​​ Supportive measures include use of support stockings and increased dietary salt and fluid intake. Slower dose titration, decreasing or dividing doses of antipsychotic medication, or switching to an alternative antipsychotic may be required.[65]​ Patients should be counseled to assume upright positions slowly as a precautionary measure.

  • Anticholinergic adverse effects of antipsychotic treatment can be divided into peripheral (e.g., dry mouth, constipation, blurred vision, urinary retention) and central (e.g., delirium, impaired learning and cognition). Patients usually develop tolerance to dry mouth; rinsing with water or chewing sugarless gum may help. For blurred vision, a temporary reduction of the medication dosage may be indicated. If acute urinary retention or delirium occurs, antipsychotic medication needs to be discontinued. If constipation develops, initial treatment can include stool softeners or osmotic laxatives.[65]​ Anticholinergic adverse effects are often dose-related and may improve with lowering of the dose or administering the medications in divided doses.[65]​

Increased risk of blood-borne viruses: there appears to be an increased risk of blood-borne viruses in patients with serious mental illness, including schizophrenia.[79][80]​ One Swedish population-based study found that, after accounting for sociodemographic factors, the odds of HIV were 2.57 times higher in people with serious mental illness than in the general population; the odds of hepatitis B virus were 2.29 times higher; and the odds of hepatitis C virus were 6.18 times higher. Substance use was found to contribute most to this increased risk, indicating a need to identify comorbid substance use in patients with serious mental illness, as well as to identify interventions to prevent infection with blood-borne viruses.[237]

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