John Boronow, M.D., the Service Chief of the Psychotic Disorders Unit at Sheppard & Enoch Pratt Hospital, has worked with psychotic patients since the time he trained at NIMH almost twenty years ago. Below are some comments from a recent interview.
In many respects, the treatment of schizophrenia at Sheppard Pratt involves the traditional struggle of rendering good care to someone with a chronic illness. This is often a surprise to our residents who have come to the hospital with basic science expertise and a psychopharmacologic orientation. Residents have generally seen patients in controlled inpatient settings, and they often feel the work is done when they've dictated the discharge summary. In fact, this is often where the patients' work begins, as they attempt to reenter the "real world" outside the hospital. I teach residents about the complexities of psychotic illness and emphasize not just drugs and receptors, but what I refer to as the lives of these patients-what happens to them, where they end up, and how they feel about it. In this era, I also emphasize practical economic issues, such as who pays for their care. It is crucial that residents understand the politics and the complex funding of chronic mental illness. For example, who will pick up the tab for a $5,000 course of Clozaril? Medicare does not pay for drugs. Can the patient afford the rehabilitation program, or a day hospital, or a group home, each of which may require a different payor? You cannot make clinical treatment decisions anymore without knowing who will pay for it. Otherwise at the time of discharge, everything you planned falls apart.
At Sheppard Pratt, we have been fortunate to have a day hospital and residential setting designed specifically for the psychotic patient right on the grounds of the hospital campus. We have tried to forge a good working relationship with Maryland Health Partners (MHP), the managed care organization that administers the Medicaid benefit in Maryland which is responsible for a large portion of our patients. MHP has the flexibility to take advantage of the full continuum of services we offer. Our median length of stay is 11 days, but unlike commercial managed care organizations, Maryland Health Partners recognizes the severity of the disability in the chronically ill. We can often work out a step down program to partial care units we staff. Schizophrenic patients need long term care in an era where long term care is not always easy to get. And while money exists in the public sector, it is limited. So we cobble together services which provide as much continuity of support as the current system will allow.
Another set of difficulties is inherent in chronic disease itself. The problem of invigorating and energizing someone with chronic mental illness is still formidable. Negative symptoms continue to be one of the biggest difficulties in the rehabilitation process. Newer "atypical" antipsychotic medications have been less useful for negative symptoms than advertising would suggest. In fact, newer atypical medications can cause difficulties, and we are seeing numerous cases of polypharmacy in which patients are placed on both atypical and typical drugs. This was not the case in the past; i.e., you were not apt to see a patient on haloperidol and chlorpromazine. But patients are now routinely admitted on both haloperidol and olanzapine, thus complicating the clinical picture. The possible reasons for this relate to the fact that the atypical antipsychotic drugs have fewer side effects and are well tolerated by patients. However, these drugs do not always work as well for acutely ill patients or for those chronic patients who decompensate. Thus, two or more drugs are used. We are also seeing patients who present in a quasi-like psychotic state; that is, they are well groomed, and sleep well, but they hallucinate. In other words, there is some psychotic breakthrough, but the clinical picture is not that associated with the usual psychotic relapse with a disheveled appearance, sleeplessness and florid disorganization.
We see more violent patients, but that is not uncommon in hospitalized populations these days. On our inpatient service, we have put into effect an Aggression Observation Level (similar to a suicide precaution) whereby multiple staff approach any patient requiring hands-on intervention, such as the taking of vital signs. Such a patient is also brought to the attention of any new staff member at each shift change. The object is to prepare ourselves with new skills in order to be able to treat a more aggressive population than previously seen at Sheppard Pratt.
Funding for schizophrenia research has been much improved in the past decade, in part due to the conceptualization of the illness as a brain disease. But the biological model detracts as much from clinical care as it augments our understanding of the illness. The treatment of chronic psychotic illness is labor intensive and time consuming, and requires a full range of services. There is nothing quick or magic about it. Resources for nonbiological treatments remain limited, and research in this domain is much neglected in recent years. Still, the hope and expectation for a fundamental breakthrough in the underlying biology of this devastating disease is as high now as it has ever been, since Kraepelin and Bleuler first developed the concept of schizophrenia at the beginning of this century.