What is the initial treatment plan for a patient with schizophrenia?

Follow-up Questions for Patients with Schizophrenia

At every follow-up visit, systematically assess medication effectiveness, side effects, safety risks, physical health parameters, functional status, and adherence to create a comprehensive monitoring framework that reduces morbidity and mortality.

Medication Effectiveness and Symptom Monitoring

Positive Symptoms Assessment

• Ask specifically about hallucinations: "Are you hearing voices or seeing things that others don't?" Document frequency, intensity, and content 1
• Evaluate delusional thinking: "Do you have any beliefs that others find unusual or hard to understand?" 1
• Assess thought disorganization: Observe speech patterns for tangentiality, loose associations, or incoherence during the interview 2
• Use quantitative measures: Administer standardized scales like the PANSS to track symptom severity objectively at each visit 1

Negative Symptoms Assessment

• Evaluate motivation and goal-directed behavior: "How are you managing daily activities like showering, cooking, or cleaning?" 3
• Assess social engagement: "Are you spending time with family or friends? How often?" 3
• Screen for anhedonia: "Are you able to enjoy activities that used to give you pleasure?" 4
• Document flat affect: Note emotional expressiveness during the clinical encounter 4

Cognitive Function

• Assess attention and concentration: "Are you able to focus on tasks or follow conversations?" 1
• Evaluate memory: "Do you have trouble remembering appointments or recent events?" 3
• Screen for executive dysfunction: "Can you plan and organize your daily activities?" 3

Safety Assessment (Critical at Every Visit)

Suicide Risk

• Directly ask about suicidal ideation: "Have you had thoughts of hurting or killing yourself?" 1
• Assess for specific plans and intent: "Do you have a plan? Do you intend to act on these thoughts?" 1
• Remember that 4-10% of patients with schizophrenia die by suicide, with highest risk in males during early illness course 1
• Consider clozapine if suicide risk remains substantial despite other treatments 1

Violence and Aggression Risk

• Ask about aggressive thoughts or behaviors: "Have you had thoughts of hurting others? Have you acted on these?" 1
• Evaluate command hallucinations: "Do the voices tell you to hurt yourself or others?" 1
• Consider clozapine if aggressive behavior remains substantial despite other treatments 1

Medication Side Effects and Tolerability

Metabolic Monitoring (Essential for Reducing Mortality)

• Measure weight at every visit: Document BMI and compare to baseline 1, 5
• Check fasting glucose and lipids: Screen at baseline, 3 months, then annually (more frequently if abnormal) 1, 5
• Ask about increased appetite or dietary changes: "Have you noticed changes in your eating habits?" 1

Extrapyramidal Symptoms

• Screen for parkinsonism: "Do you feel stiff or have trouble moving? Are your movements slower than usual?" 1
• Assess for akathisia: "Do you feel restless or unable to sit still?" Observe for pacing or fidgeting 1
• Evaluate for dystonia: "Have you had any muscle spasms or abnormal postures?" 1
• Screen for tardive dyskinesia: Observe for involuntary movements of face, tongue, or extremities using standardized examination 1

Other Side Effects

• Assess sedation: "Are you feeling overly tired or sleeping too much?" 6, 7
• Screen for sexual dysfunction: "Have you noticed any changes in sexual interest or function?" 1
• Evaluate for orthostatic hypotension: Check blood pressure sitting and standing 6
• Ask about anticholinergic effects: "Do you have dry mouth, constipation, or blurry vision?" 1

Medication Adherence

Direct Assessment

• Ask non-judgmentally: "How many doses of your medication have you missed in the past week?" 1
• Identify barriers: "What makes it difficult to take your medication regularly?" 1
• For patients with poor adherence history, discuss long-acting injectable antipsychotics 1, 5

Reasons for Non-Adherence

• Assess insight: "Do you believe the medication is helping you?" 3
• Evaluate side effect burden: "Are side effects making you want to stop the medication?" 1
• Screen for substance use interfering with adherence 1

Physical Health Monitoring (Critical for Reducing Mortality)

Cardiovascular Risk Factors

• Monitor blood pressure at every visit 1, 5
• Assess tobacco use: "Are you smoking? How much?" Offer cessation support 1
• Screen for diabetes and hyperlipidemia with laboratory testing 1, 5

General Health Maintenance

• Ask about preventive care: "When was your last physical exam? Are you up to date on cancer screenings?" 1
• Evaluate diet and exercise: "What does a typical day of eating look like? How much physical activity do you get?" 1
• Screen for comorbid medical conditions that contribute to increased mortality 1, 5

Substance Use Assessment

Comprehensive Screening

• Ask about all substances: "Are you using alcohol, marijuana, stimulants, or other drugs?" 1
• Quantify use: Document frequency, amount, and route of administration 1
• Assess impact on symptoms: "Do you notice your symptoms worsen when you use substances?" 1
• Address comorbid substance use disorders as they significantly contribute to morbidity and mortality 1

Functional Status and Quality of Life

Daily Living Activities

• Assess self-care: "Are you able to manage bathing, grooming, and dressing independently?" 3
• Evaluate living situation: "Where are you living? Is it stable housing?" 1
• Screen for homelessness or housing instability 1

Social and Occupational Functioning

• Ask about employment or education: "Are you working or in school? How is that going?" 1, 5
• Evaluate social relationships: "Do you have supportive people in your life?" 1
• Assess family involvement: "How often do you see family members?" 1
• Refer to supported employment services if patient desires work 1, 5

Psychosocial Treatment Engagement

Current Interventions

• Ask about therapy participation: "Are you attending cognitive-behavioral therapy sessions?" 1, 5
• Evaluate engagement with coordinated specialty care (for first-episode patients) 1, 5
• Assess family intervention participation if family is involved 1
• Screen for need for assertive community treatment if history of poor engagement or frequent relapses 1, 5

Treatment Response and Adjustment

Determining Treatment Resistance

• If symptoms persist after 4-6 weeks at therapeutic dose, consider switching antipsychotics 6, 7
• After two failed adequate trials of different antipsychotics, initiate clozapine for treatment-resistant schizophrenia 1, 5
• Document specific symptoms that are treatment-resistant 5

Maintenance Treatment

• For patients who have improved, continue the same antipsychotic medication 1
• Maintain treatment long-term as 70% of patients require lifetime medication 2
• Periodically reassess the need for continued treatment and lowest effective dose 6

Documentation Requirements

Comprehensive Treatment Plan

• Ensure a documented, person-centered treatment plan exists that includes both pharmacological and non-pharmacological interventions 1
• Update the plan based on current symptom severity, functional status, and treatment response 5
• Document patient goals and preferences for treatment 1, 3