TACOMA, WA—Schizophrenia is a disease that erects barriers between the person suffering from it and their ability to lead a fulfilling and “normal” life within their community. Besides the general public’s lack of understanding about mental illness and the stigma that is attached to it, cognitive deficits created by the disease, and the side effects of the very potent medications that are used to treat it, also pose challenges. All of these factors make life harder for the estimated 2.2 million people suffering from schizophrenia in the United States.

The work being performed by Department of Veterans Affairs clinicians and researchers within the Model Schizophrenia Program at the VA Puget Sound Healthcare System is focused on just that: improving the quality of life of schizophrenia patients. Despite ongoing advances in pharmacotherapy, schizophrenia continues to be a chronic and disabling disease that gravely impacts quality of life for patients and families. The MSP is tasked with finding ways to alleviate that impact.

Improving Quality of Life

MSP is part of VA’s network of Mental Illness Research, Education, and Clinical Centers (MIRECCs)—centers scattered across the country that focus on different aspects of mental illness research. The MSP, part of the VISN 20 MIRECCs, is centered at the VA medical center in Tacoma, WA. MSP encompasses all of that facility’s clinical and research programs relating to schizophrenia patients, explained Andre Tapp, MD, the program’s director, in a phone interview with U.S. MEDICINE.

“We have inpatient services; we have a variety of outpatient services that include a recovery center; we have residential care program, in which we’re sponsoring and contracting with some facilities to deliver service and support patients in the community; and we have an intensive case management program where new patients are followed very intensely by a case manager who has a caseload of approximately 20 patients,” Dr Tapp explained. “We also have a supported work program with a variety of levels of support and supervision to the work activities. And we have a small research component that is attached to that as well.”

Much of that small research component has been focused on the medications that schizophrenia patients have been taking, and what can be done to improve the pharmaceutical regimens and deal with the side effects that arise from them. “The focus of our research here is driven by what we observe are the clinical needs of our patients,” explained Annette Kennedy, PsyD, a research leader at the MSP. “In the VA in general, and certainly here at our site, many of the schizophrenic patients are chronic, relatively well-functioning, and tend to have the type of problems that are associated with that presentation of the illness—predominantly negative symptoms which are associated with well-functioning, cognitive deficits, and a variety of medical problems that are secondary both to the schizophrenia itself as well as to the treatments for schizophrenia.”

In short, the patients VA deals with are focused on searching for ways to become functional members of their community despite their disease. Finding a better drug regimen—one that is easier to take and has fewer side effects—is one way of accomplishing that goal.

MSP researchers have been active in a number of trials through the CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness) project, a study run through the National Institute of Mental Health. Previous studies have looked at comparing different antipsychotic treatments, studying polypharmacy with antipsychotic medications, and studying the metabolic effects of those antipsychotics. “We’ve also participated in some collaborative studies in the veterans, where we’ve studied the effects of extended injection of [the antipsychotic] risperidone and those injections compared to other traditional treatments,” added Dr. Tapp.

Too Many Drugs

Through the work MSP has done with the CATIE project, Dr Tapp and his fellow researchers began to focus specifically on the sheer quantity of drugs that schizophrenia patients end up taking over the course of their lives. “Often patients will be followed for a number of years, even decades, and they take more and more medications. Typically one medication gets added on, and then another, and nothing ever gets taken away,” explained Dr. Kennedy. “It’s not unusual for chronic patients to be taking 5 or 6 different psychotropic medications—an antipsychotic agent and an antidepressant, and various other things—and you have things for side effects and you have things for sleep and so on.”

The result is that a patient might be taking more drugs than necessary in instances when fewer medications would produce the same effect. “We did a small, basically quality improvement project, but it was also a clinical research project, where we looked at whether it was possible to optimize the psychotropic medications that our patients were using in the interest of reducing those medications,” Dr. Kennedy said. “In the course of their normal clinical practice, can psychiatrists safely reduce the number of psychotropic medications patients are taking without adverse effects to their psychiatric stability? In pilot work, we’ve found that that is true.”

Studies performed through the MSP have shown that clinicians can reduce a patient’s regimen by an average of 1.5 medications, and the patient can retain the same overall rating of cognitive stability.

A System of Recovery

The last decade has seen the mental health field start moving to accommodate a new paradigm—one based on recovery, where the goal is not just to treat a patient’s symptoms on an inpatient basis, but to help them become part of their community. “It starts with an assessment that includes the goal that the patient feels he or she wants to achieve, so we are starting from a plan in which the patient is an included part of the design in some ways,” explained Dr. Tapp. “They are supported in that context by a variety of staff, from case manager to psychiatrist. It’s a multifaceted process that includes a variety of participants and in which the patient himself hopefully directs most of the plan.”

This new paradigm gives the patient more power in determining just how he or she will go about dealing with their disease. “Recently there’s been a lot of money [directed by Congress] that’s gone into the VA system to implement recovery-based services, [including services for patients with] severe mental illness,” explained Dr. Kennedy. “One of the ways that’s translated to services for our veterans is that we revamped our day program, which has been a day-treatment model based on what has been termed a clubhouse model.”

The term “clubhouse model” became prominent in the 1980s, and refers to treatment programs that deal more with helping patients develop independence rather than solely managing their disease. The program was designed to resemble a clubhouse, with patients learning social skills and with fewer distinctions between physician and patient. “Now we’re using more of a college campus model where, instead of people going into day treatment all day, sitting there passively, being a passive recipient of whatever material or information that the facilitators wish to give them, we offer a variety of activities and a variety of miniclasses or seminars in topics that are of interest to the veteran. And they get to pick and choose which of those they attend. They pick and choose the frequency in which they come to the program. Some people may be coming once a week, or 5 days a week,” Dr. Kennedy explained.

Clinicians are also looking to integrate patients who, though they suffer from different diseases, have the same life goals. “Typically in the past, things have been very segregated by diagnosis,” Dr. Kennedy noted. “So an individual with PTSD probably would have little contact in the treatment with individuals with schizophrenia. Now what we’re really addressing are the issues and concerns [of the patients] instead of the diagnosis. So, for example, in our back to work program we have OIF/OEF veterans that are working alongside chronic schizophrenia patients because they have similar concerns in terms of their desire to get back to work and learning work skills.”

Vocational program leaders at the Tacoma VAMC have worked for years to establish and maintain relationships with employers in the surrounding community in order to help veterans find employment that can accommodate their needs. “Often that actually involves a social worker or case worker going out and initially working with the veteran in learning the new job, and then later, once they’re established, having frequent contact with the employer,” Dr. Kennedy explained. “Our employment people are constantly working to retain those relationships and develop new ones. Frankly, it’s one of the things that VA in general has been very difficult for us in the current economic climate to maintain those community relationships with employers. Our team has worked very hard and has been quite successful in our efforts to maintain those relationships. The VA has been hit hard in that regard.”

Dr. Tapp admitted that, while the clubhouse recovery model concept was anecdotally well affirmed and heavily supported by patient advocacy groups, it still needs further study. “There is still not enough research to prove conclusively the outcome that can be obtained by this new model,” he said. “Comparing this delivery system of a recovery base to a more traditional system needs to be continued and confirmed in some way.”

back to August articles