Breakthrough of Symptoms Despite Compliance with Maintenance Treatment: If the patient experiences a breakthrough of symptoms while complying with maintenance antipsychotic treatment, physicians usually suspect that the medication regimen was suboptimal: it had failed to prevent the relapse, so a higher dose must be needed. However, there seems to be no evidence to support this supposition. In fact, one study in newly admitted exacerbated patients who had been complying with neuroleptics found no difference in outcome between patients whose dose was increased and those who remained at the preadmission dose. Both groups did very well, although the group with the dosage increase developed more EPS.¹ This study suggests that nonspecific effects of hospitalization might account for much of the improvement typically seen when breakthrough patients are admitted. The corollary of this is that the exacerbation may have been precipitated by a lack of structure and support in the community (or intolerable levels of "expressed emotion" by those interacting with the patient) and thus the exacerbation may not necessarily reflect a deficiency in the medication regimen.²,³
Thus, the first intervention might be to attempt to remove the patient from the external stressors, perhaps by admitting to an inpatient unit or day hospital.(4) A sedative-hypnotic may be used as needed, temporarily, and if the baseline antipsychotic is increased this should be a temporary measure in many cases. Other psychosocial interventions may also be helpful.(5,6)
Looking back behind the immediate precipitants of the acute exacerbation, the clinician should assess the patient's previous level of recovery when stabilized (See Table at the link). If the level of recovery was excellent (i.e. normalized activity) with minimal side effects, it may be reasonable to ultimately discharge the patient on the admission medication at the same dose. Click here to receive this recommendation and obtain the outcome tracking number.
If the level of recovery was, in retrospect, less than excellent, a medication change may be appropriate (for example, if it was characterized by persisting disability from positive and negative symptoms, impairment in work or social function, need for a supervised living situation, lack of insight into the need for treatment, or disabling side effects).
The unsatisfactory response might have been due to side effects from the original medication regimen. The next question will focus on identifying and managing certain (not all, at this point) side effects in order to improve the response. The algorithm will proceed from there to evaluate the adequacy of the antipsychotic regimen the patient was on, in terms of dose and duration, and make recommendations for a switch to a different antipsychotic, usually an atypical antipsychotic, as appropriate.
