Day one of EPA 2015 and we spoke with Professor Dieter Naber emeritus Professor of the Department of Psychiatry and Psychotherapy at the University Medical Center Hamburg-Eppendorf, Germany. Our correspondent was lucky enough to listen in on a video interview during which Professor Naber shared some of his personal thoughts on contemporary issues in schizophrenia management. The full interview is available as an on-line educational programme on the website psychiatryspeaks.com.
When you know your patient has schizophrenia how do you communicate the diagnosis and discuss treatment plans?
It is really important to start by understanding what the patient considers is their biggest problem and their ideas about treatment goals. Most patients say they want to live as normal a life as possible.
What we need is a therapeutic alliance between the psychiatrist and patient and of course for many patients still living at home or with caregivers – these family members and carers have to be part of the alliance too.
Young patients have often read about schizophrenia on the internet and can have preformed ideas about their condition and what we need to do is induce hope and communicate that it is possible to live a normal life. Of course this requires embarking on a suitable treatment plan and often requires that the patient has the necessary support.
Patients with schizophrenia are a very heterogeneous group and no one plan works for all patients.
Breaking down the barriers
There can still be a lot of stigma associated with a schizophrenia diagnosis. Patients can be reluctant to admit to their condition. Some blame their drug use for their symptoms. Many deny the diagnosis. We often use the term psychosis rather than schizophrenia initially and before we are certain of the diagnosis. This can help destigmatize.
Communicating with the patient and caregivers is important right from the outset. Psychiatrists and patients should have the same expectations and goals but of course what the patient wants to achieve is often expressed in terms of vocational or social goals.
We also have to judge patient by patient what a patient hears and what they need to hear. It is often a delicate balance. In the acute phase of the condition we want to get things under control. Longer term we need to gain the patient’s trust and give them insight into their disease and how it can be managed.
What for you are the most important long-term treatment goals that allow patients to live a meaningful life?
In the past we used to focus a lot on controlling the positive symptoms – the voices – the hallucinations. Yet it is often the other side of the condition – the negative symptoms and the depression that have a negative impact on quality of life.
Patients want to live as normal a life as possible and achieve their life goals.
It’s our job to get to know the patient very well and then inform the patient of the treatment options – explaining both the potential benefits and the adverse effects of treatment. There has to be shared decision-making. We need to empower the patient. Autonomy is a very important goal for some patients. That means we need to help find the right drugs and dose for patients and all treatment has to be individualized. Treatment needs to work for the patient today, tomorrow and next year.
Patience and endurance
Some patients want too much too fast and when a treatment works – there are some who want to immediately reduce their treatment dose – thinking that if their condition is better they therefore need less drug treatment. For such patients communication and support are really important.
With optimal management the potential for patients to live a near normal life can be good. The earlier we can start treatment the better – just as in other areas of medicine.
We also need to help patients who don’t tolerate therapy well or experience relapses and again this is where establishing or re-establish the therapeutic alliance is important.
Dinner-time drug talk
Non-adherence to treatment is often the biggest issue. For some patients this may mean rethinking treatment. Some patients find they actually prefer to move to a long acting injectable for example. The whole issue of adherence to daily treatment can place great strains on families and on the patient carer-giver relationship. The daily ‘dinner-table’ conversation about whether or not the patient has taken their drugs can become a strain point for all concerned. It’s often a carer or family member that can see the benefits for all involved in moving towards a long-acting injectable that ensures dose stability for long-term management.