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* Schizophrenia Spectrum Disorders
Psychosomatics 44:12-23, February 2003
© 2003 The Academy of Psychosomatic Medicine

Review

Clinical Experience With the Management of Schizophrenia in the General Hospital

Oliver Freudenreich, M.D., and Theodore A. Stern, M.D.

Received April 8, 2002; revision received July 16, 2002; accepted Aug. 5, 2002. From Massachusetts General Hospital Schizophrenia Program, Freedom Trail Clinic; and Harvard Medical School, Boston. Address correspondence and reprint requests to Dr. Freudenreich, Massachusetts General Hospital Schizophrenia Program, Freedom Trail Clinic, 25 Staniford St., 2nd Fl., Boston, MA 02114; ofreud{at}massmed.org (e-mail).


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 REASONS FOR CONSULTATION AND...
 CONCLUSIONS
 Appendix 1: Maxims for...
 REFERENCES
 
On the basis of experience with 74 psychiatric consultations involving patients with schizophrenia admitted to a general hospital medical or surgical ward over a 17-month period (3% of the psychiatric consultations during that period), the authors identified 10 types of problems leading to requests for consultation. The authors used these categories to organize recommendations for management of patients with schizophrenia in the general medical hospital. In addition to conducting conventional consultations, the consultation psychiatrist in such cases often has a role in educating hospital staff about schizophrenia and in serving as a physician for the mentally ill.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 REASONS FOR CONSULTATION AND...
 CONCLUSIONS
 Appendix 1: Maxims for...
 REFERENCES
 
"Everything that is good for the healthy is good for the schizophrenic. Everything that is bad for the healthy is also bad for the schizophrenic (sensu Bleuler)."1

The management of medical disorders in the general hospital becomes more complicated when the patient also has schizophrenia and when the treating clinician lacks information about how the diagnosis and treatment of medical conditions can be affected by comorbid psychotic illness. Few chapters in medical or psychiatric textbooks provide specific suggestions for the medical care of the hospitalized patient with schizophrenia (for notable exceptions see Goff et al.2,3). However, within the past decade, problems related to the medical care of this population have been recognized increasingly, and overviews on the topic have been written (see Vieweg et al.,4 Goldman,5 and Gilmore et al.6). Nevertheless, the needs of the consultation psychiatrist have been largely overlooked.

In an effort to remedy this problem, we used the experience of the psychiatric consultation service of Massachusetts General Hospital to review problems commonly encountered by patients with schizophrenia when they are admitted to a general medical or surgical ward. Our review is intended for psychiatric consultants and nonpsychiatric staff who manage patients with schizophrenia.


  METHODS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
REASONS FOR CONSULTATION AND...
 CONCLUSIONS
 Appendix 1: Maxims for...
 REFERENCES
 
During a 17-month period (from December 1998 to May 2000), the Massachusetts General Hospital psychiatric consultation service received 74 consultation requests that explicitly contained a reference to a schizophrenia spectrum disorder or performed consultations that were coded for schizophrenia (ICD code 295) by the consultant. These 74 consultations accounted for only 3% of the total number of consultations fielded by the service (N=2,564) during that period.

The reasons for psychiatric consultation were broken down into 10 categories (as shown in Table 1). These categories were used to organize management strategies for the patient with schizophrenia in the general medical hospital. In addition, we summarized key teaching points as maxims, which are listed in Appendix 1.


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TABLE 1. Reasons for Psychiatric Consultation Requests (N=74) for Patients With Schizophrenia in a General Hospital Over a 17-Month Period, by Relative Frequency




  REASONS FOR CONSULTATION AND SUGGESTED MANAGEMENT STRATEGIES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 REASONS FOR CONSULTATION AND...
CONCLUSIONS
 Appendix 1: Maxims for...
 REFERENCES
 
"Please see this patient with schizophrenia."
Almost one-third of all schizophrenia-related consultations simply requested that we see the patient with schizophrenia; this was consistent with the experience of other psychiatric consultation services.7 Some of those consultations turned out to be simple requests for coordination of outpatient follow-up or for transfer of patients back to the psychiatric unit from which they came. The majority of requests, however, reflected no specific question; the patient's psychiatric diagnosis alone led to the consultation. On the positive side, one might view this type of nonspecific request as a blessing. It provides the consultant with access to these patients, who are at risk for receiving inappropriate care (either under- or overmedicalization) because of physician-related factors (countertransference) or patient-related factors (e.g., opposition or passivity).

This type of consultation requires the awareness that mental illness evokes fear and is poorly understood by medical staff. Although surveys of the general population have shown that the term "schizophrenia" can evoke fear, to our knowledge, no study has queried nurses about their fears of patients with schizophrenia. Fear of violence was cited by general practitioners in Great Britain as one reason why they might not add a patient with schizophrenia to their practice.8 Moreover, psychiatric patients in general are perceived as difficult and unrewarding, both by physicians and by medical students.9,10 Education about the clinical aspects of the disorder should translate into more appropriate care by health care professionals.

A useful framework for teaching about the clinical aspects of schizophrenia includes identification of predominant symptom clusters (psychosis, disorganization, negative symptoms, cognitive deficits) and development of a patient profile based on the relative contributions of each dimension. Such "profiling" allows behaviors to be reframed in relation to aspects of pathology outside the patient's control. For example, "personality-disordered" behaviors can be recognized as evidence of disorganization, "inflexibility" as evidence of cognitive deficits, and "laziness" as stemming from the avolition of negative symptoms. This reframing can help prevent frustration and withdrawal of care, but, for nonpsychiatric staff who prefer psychosocial explanations rather than a more medicalized view of serious psychiatric illness, making this transition is not an easy task.11

Applicable maxims: Recognize that the word "schizophrenia" evokes fear in the heart of staff members. Expect that the patient with schizophrenia is perceived as "irrational," "oppositional," and "lazy." It is twice as difficult for psychiatric patients to appear half as normal.

Providing help with depression
While depression can occur in patients with schizophrenia,12,13 other factors, e.g., delirium,14 a misinterpretation of negative symptoms (primary or drug-induced secondary symptoms),15 apathy, or demoralization,16 must also be considered. Depression contributes to poor quality of life, and it is a risk factor for suicide.17 Therefore, use of antidepressants, which are effective, should be pursued aggressively. However, antidepressants should be used only when a clear indication exists; they should not be used just to appease the staff of another clinical service. Stimulants (e.g., dextroamphetamine or methylphenidate) can also be used for depression, to counteract medication-induced sedation (e.g., from clozapine18), or to combat apathy. Stimulants, which in general are relatively safe, have the potential to aggravate psychosis.

For most consultation services, "depression" is the most common reason for consultation. Beyond recognizing the need for a differential diagnosis of depression, one must also consider that "depression" is lingua franca to convey patient and/or staff distress. As such, the process of consultation is as important as the content.

Applicable maxim: Develop a differential diagnosis of "depression."

Assessing competency of a patient who refuses treatment
The wording of the saying "I may be crazy but I am not stupid" is not intended to minimize or belittle the person with psychotic illness. However, it succinctly captures a commonly misunderstood truth: having schizophrenia does not make someone unable to make rational decisions. Even disorganized and delusional patients can express their opinions, e.g., on whether to have or to refuse a necessary amputation. The capacity evaluation of a patient with psychosis follows the same principles as does the capacity evaluation in a nonpsychotic patient, except that evaluation of a patient with psychosis requires a determination of whether delusions are contributing to treatment refusal. Foremost, the evaluation is situation specific. Research has shown that education can improve a patient's decisional capacity (e.g., to give informed consent to participate in schizophrenia research),19 and, by extension, a patient's medical decision making. The consent process has to be individualized and has to take into account an individual's limitations.20

However, a patient with schizophrenia may have clinically relevant deficits in cognition, with memory, attention, and executive function most severely affected.21,22 It is the degree of cognitive deficits that forms the biggest obstacle to informed consent.19 Assessment of frontal lobe function is an important part of the capacity evaluation, and it requires that the psychiatrist assess the patient's ability to "anticipate the pragmatic consequences downstream of placing an act now" (G.B. Murray, personal communication, 1999). Some clinicians have adopted a pragmatic stance that has been termed "Don't ask, tell,"23 which employs a direct, paternalistic style that often leads to treatment compliance. At the same time, one must guard against interpreting a patient's response of "yes" or the patient's simply going along with treatment as the ability to consent to the interventions. When treatment options are being discussed with psychotic patients, language should be as concrete as possible, since figurative language is often not understood.24

Applicable maxim: Being "crazy" (psychotic) does not mean that the patient is "stupid" (incompetent).

Providing help with medication management
The psychotropic medication that is prescribed for those with schizophrenia may result in iatrogenic complications and lead to a medical admission. Possible drug-induced signs and symptoms should be searched for. This assessment may be straightforward, such as considering that risperidone may have induced galactorrhea (associated with hyperprolactinemia). The knowledge that the side effect profile for atypical antipsychotics (e.g., clozapine, olanzapine, and quetiapine) differs from that of typical antipsychotics25 is crucial. Aside from being at risk for long-term morbidity associated with weight gain, diabetes, and lipid abnormalities,26 patients receiving atypical agents might also be at higher risk for pancreatitis from rapidly rising levels of triglycerides27 or from diabetic ketoacidosis.28,29 The metabolic consequences of psychotropics constitute an area of active investigation. Additional studies are needed to delineate which metabolic side effects are common to all antipsychotics and which are specific to a particular drug or class.

Typical antipsychotics commonly cause neurologic symptoms that can be confused with psychiatric presentations. Often overlooked are extrapyramidal side effects from medically used medications with antidopaminergic properties such as metoclopramide.30,31 Akinesia and parkinsonism can be mistaken for negative symptoms or depression, akathisia for agitation, and acute dystonia for psychosis. Tardive dyskinesia can affect muscles of the respiratory or gastrointestinal system, leading to a broadening of the differential diagnosis. If only a single muscle group (particularly the muscles of speech or respiration) is affected, the diagnosis is difficult. Often there is evidence of tardive dyskinesia in other body parts, which may suggest the diagnosis.32 Patients can be unaware of the their involuntary movements.33

Potential drug interactions between psychotropics and nonpsychotropics are legion.34 Therefore, knowledge of metabolic pathways is helpful in the prediction of drug interactions. Antipsychotics are mainly metabolized by the cytochrome P450 3A4 isoenzyme system, with varying contributions from 1A2 and 2D6. All antipsychotics have lower plasma levels in the presence of a strong 3A4 inducer. Antipsychotics with significant 1A2 contributions (most notably clozapine and olanzapine) are susceptible to the effects of smoking. Olanzapine and ziprasidone are additionally metabolized by phase II metabolism. This property provides some protection against P450 drug interactions. Medications should be reviewed to predict if antipsychotic drug levels will be altered by drug interactions, e.g., will be too low (ineffective) or too high (which adds morbidity, such as in the case of clozapine-induced seizures). Examples of important interactions include inhibition of clozapine metabolism by erythromycin or fluvoxamine, and accelerated antipsychotic metabolism by inducers of the 3A4 isoenzyme system, such as carbamazepine or phenytoin (see Table 2). Adding psychotropics can conversely affect the drug levels of nonpsychotropic medications. Of particular clinical concern are potent inhibitors of cytochrome isoenzymes. Examples of such inhibitors are found chiefly among antidepressants (such as nefazodone for 3A4, fluvoxamine for 1A2, or fluoxetine and paroxetine for 2D6) and less so among antipsychotics (phenothiazines weakly inhibit 2D6).


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TABLE 2. Metabolic Pathways and Active Metabolites of Selected Antipsychotic Medicationsa



A different type of drug interaction can occur when binding to serum proteins is altered and the free fraction of a drug increases. This interaction becomes important in severely ill patients or in patients who are malnourished, or when highly protein-bound agents are combined, leading to an increase in the free fraction of a drug (e.g., the interaction of valproate and acetylsalicylic acid35).

Serial clinical exams are one safeguard against the effects of serious drug interactions. In addition, serum drug levels may be obtained for most antipsychotics and should be obtained in selected cases, not for purposes of finding an optimal drug dose but to rule out extremes of metabolism that lead to very low or very high drug levels.

Applicable maxim: Carefully review polypharmacy.

"This patient is homeless." (Or, "Please transfer to psychiatry.")
Unlike the patients with schizophrenia in the past who were cared for in asylums, more recent cohorts of persons with schizophrenia are characterized by homelessness, poor compliance, and substance use (with its sequelae of HIV infection, hepatitis C, tuberculosis, or sexually transmitted diseases36). For these difficult-to-treat patients, the call for a transfer to psychiatry tends to come earlier rather than later in the hospital course. While a transfer might be indicated, often the hospitalization is requested because of homelessness and not because of psychiatric symptoms. The reason for admission and the need for a medical workup should be clarified. While it has been well established that medical morbidity is substantial in patients with schizophrenia,37 medical workups for psychiatric patients are often incomplete. One report showed that fewer medical diagnoses were made among chronic psychiatric patients than among patients with medical admissions and that chronic psychiatric patients were readmitted more often.38 Furthermore, it appears that patients with schizophrenia are treated later, and in acute phases of medical illness. This pattern may contribute to an increased mortality rate.39 Only a high index of suspicion will prevent the clinician from missing an undiagnosed physical disease not initially predicted by the symptoms on referral.40 It is worth recalling that many patients with schizophrenia are unable to list all of their medical illnesses and cannot be relied upon for medical history.41

It has become increasingly clear that patients with schizophrenia often receive substandard care. They have higher case fatality rates for cancer42 and worse outcomes after orthopedic surgery,43 and they receive standard interventions less often after cardiac events.44 The Massachusetts Department of Mental Health recently made public preliminary morbidity and mortality figures from its database, which showed a sevenfold increase in mortality rates from cardiovascular disease in patients aged 25 to 44 with schizophrenia, compared to those without schizophrenia (unpublished data, Massachusetts Department of Mental Health, 2002). It is therefore necessary to review the patient's medical care and to advocate for the schizophrenic patient.

Applicable maxim: Consider yourself the patient's only physician.

"The patient is in restraints." (Or, "Evaluate the risk of suicide/homicide.")
Three scenarios are encountered in which a risk assessment is requested: when a hospitalized patient is acutely agitated, psychotic, or aggressive; when a patient has survived a suicide attempt or is threatening suicide; or when a patient is known to have schizophrenia. Assessment of the first two scenarios follows standard guidelines for risk assessment. The third scenario is often easy to resolve after establishing some minimal alliance. However, a patient admitted to the hospital after an episode of bizarre self-mutilation (the van Gogh syndrome) can be difficult to evaluate. Diagnostic possibilities include psychosis and personality disorder.45 Therefore, it seems prudent to consider self-mutilation as a sign of incipient psychosis (until this possibility has been ruled out).46 If the self-mutilation is based on psychotic thinking, it can be impossible to predict, and it may recur. Self-mutilation associated with psychosis may be severe and involve self-amputation,47 autocastration, or self-enucleation. In the case of autocastration, one may find a religious motivation, a theme of guilt or sexual conflict, a past suicide attempt, and major personality deviation in adult life.48 Those with command hallucinations are at high risk of violence, both against others and against the self.49 This risk is particularly high if command hallucinations occur in combination with delusional beliefs about the voices.

In cases where the patient's risk of harm to self or others is ongoing, continuous monitoring of the patient on the medical floor should be recommended, and its implementation should be checked. While a sitter is preferred over restraints when the sitter's safety can be ensured, some patients require restraints for the duration of their medical/ surgical stay. In some hospitals, restraints are used in lieu of sitters. In these cases, it is a psychiatrist's duty to take a firm stance and to recommend a sitter as the least restrictive, but effective, treatment. It helps to point out the obvious human injustice of unjustifiable restraints as well as its risks, which include deep vein thrombosis and death from pulmonary embolization.50

Applicable maxim: Respect psychotic thinking.

Help with clozapine management.
Consultations are often requested when medical/surgical staff recognize that the use of clozapine, psychiatry's "specialty drug," is not straightforward. Three aspects of clozapine use are important: clozapine may cause side effects that lead to a medical admission, clozapine cannot be simply stopped or restarted at prior doses, and clozapine is contraindicated in a variety of medical situations.

Since clozapine can affect most organ systems in the body, the reason for the medical/surgical admission should be reviewed with the possibility in mind that clozapine may have contributed to the condition. This relationship might be straightforward, such as when sepsis results from agranulocytosis or when seizures result from high-dose treatment. Often, clozapine's role is not immediately apparent, such as in cases of colon perforation and peritonitis from its anticholinergic effects51 or in cases of myocarditis and cardiomyopathy.52,53 Table 3 provides an overview of clozapine's adverse effects that can lead to a medical admission. The abrupt discontinuation of clozapine is not recommended for several reasons. First, most patients are receiving clozapine because their schizophrenic disorder has been refractory to other medications. Second, discontinuation can rapidly lead to psychosis that is difficult to control.61 Third, if clozapine is stopped for more than a few days, it has to be started at a low dose and titrated upward slowly.


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TABLE 3. Clozapine Side Effects as Presenting Problems for General Hospital Admissionsa



For patients who develop neutropenia while taking clozapine, treatment with a granulocyte colony-stimulating factor has been successfully applied.62 Another approach to increase white blood cells above the critical threshold of 1,500 neutrophils is concomitant treatment with lithium. This strategy is not indicated for agranulocytosis. If clozapine has to be stopped, an anticholinergic neuroleptic should be substituted to avoid cholinergic rebound from clozapine, a strongly anticholinergic drug, especially if the patient has been receiving a dose of more than 600 mg/day of clozapine. Another strategy to prevent cholinergic rebound involves adding 1 mg of trihexyphenidyl for every 40 mg of clozapine for several days, then weaning and discontinuing the anticholinergic within a week.63 Clozapine withdrawal can be severe and can present with delirium and psychosis.54

Continuing clozapine may be difficult in situations when the treatment needed is toxic to the bone marrow, e.g., when a schizophrenic patient needs chemotherapy for cancer.64 Similarly, a decision to start clozapine must take into account a history of chemotherapy or radiation therapy.65 A decision to start or to continue clozapine in the face of these situations requires a discussion with the patient about the risks and benefits of treatment, as well as the coordination of care between the psychiatrist, the oncologist, the pharmacist, and the drug manufacturer. A waiver must be obtained from the pharmaceutical company (e.g., Novartis or Zenith) before the drug can be dispensed by the pharmacy. In addition, some medications are potentially toxic to bone marrow and thus are relatively contraindicated. The antibiotic trimethoprim-sulfamethoxazole is a case in point.66 Recommendations should reflect the need to treat the illness that led to the admission with medications that are not toxic to the bone marrow. Often, drugs can be substituted if there is an awareness of the problem. For example, valproate or topiramate may be used instead of carbamazepine, and other antibiotics may be used instead of trimethoprim-sulfamethoxazole.

If an EEG is performed for diagnostic purposes, it is important to know that clozapine can alter the EEG, particularly by generation of slowing and spikes.67 While slowing on the EEG correlates with sedation and thus clinical "toxicity," the significance of newly appearing spikes is unclear and does not necessarily imply subclinical seizures that must be suppressed.

The following psychotropics are safe as add-on therapies: haloperidol for delirium, amphetamine for depression/apathy (although there is some risk of exacerbating psychosis), and most selective serotonin reuptake inhibitors (SSRIs) for depression. Fluoxetine (likely only at a high dose) and fluvoxamine are best avoided because they can increase clozapine plasma levels in an unpredictable way. Fluvoxamine has clearly been implicated in the dangerous elevation of clozapine plasma levels.68 Certain fluoroquinolones similarly inhibit 1A2. Given the potential for unexpected drug interactions in complicated medical scenarios, one should consider checking clozapine plasma levels, since the likelihood of seizures increases with elevated clozapine plasma levels.

Applicable maxim: Respect powerful psychotropic medications.

Evaluation of change in mental status
A complete review of how to perform a consultation for a patient with an altered mental state is beyond the scope of this paper but is available elsewhere.69 We limit our discussion to practical issues in the management of delirium, neuroleptic malignant syndrome, and psychogenic polydipsia and hyponatremia syndrome in patients with schizophrenia.

Psychosis in a patient with a known psychotic disorder may be the result of a delirium rather than an exacerbation or recurrence of the person's underlying psychotic illness. The differential diagnosis of delirium in a patient with schizophrenia is identical to that in an individual without schizophrenia. Schizophrenia does not protect against delirium. On the contrary, risk factors for delirium include advanced age, cognitive impairment, and use of polypharmacy. Thus, a contributing cause for delirium in a patient with schizophrenia is the combination of psychotropics that are active in the central nervous system. It is essential to identify and to correct the cause of the delirium.

Currently, no controlled studies suggest guidelines for the use of antipsychotics to treat a delirious patient with schizophrenia. It is important for the consultant to emphasize to the medical or surgical team that delirium trumps other considerations. Moreover, it is impossible to detect an underlying depressive syndrome in the setting of delirium. The empiric addition of antidepressants in the treatment of a delirious patient only complicates the scenario. Standard procedure dictates holding all psychotropics while treating the delirium. This approach minimizes complications. There is no need to rush to treatment of a chronic psychiatric disorder.

Several neuroleptics, of which haloperidol has been used most extensively in the general hospital setting, may be administered parenterally. Although haloperidol is not approved by the Food and Drug Administration for intravenous use, it can be given as such. Contrary to expectations, few extrapyramidal symptoms were observed when haloperidol was administered intravenously rather than orally, despite the use of large doses.70 The safe use of intravenous haloperidol requires ECG monitoring before and during treatment to be sure that the QTc interval is kept under 500 msec. Potentially dangerous QTc prolongation is best prevented by keeping the potassium level within normal limits and by keeping the magnesium level above 2.0 mg/ ml. Despite its potential association with torsades de pointes, haloperidol appears to have a relatively safe cardiac profile. Extensive experience with haloperidol makes it the best choice if an intravenous antipsychotic is indicated. The issue of psychotropic medications and QTc prolongation and the limitations of QTc prolongation in predicting adverse cardiac events such as torsades de pointes have been reviewed elsewhere.71,72

Other approaches besides high-dose intravenous haloperidol have been used for agitation in delirium. They include combining lower-dose haloperidol with lorazepam, using lorazepam alone, or using atypical antipsychotics at customary doses if oral administration is possible.73

In the case of neuroleptic malignant syndrome,74 a key to successful intervention is recognition and immediate initiation of treatment.75,76 Neuroleptic malignant syndrome should be placed in the differential diagnosis of all delirious patients who have been receiving dopamine antagonists. It is noteworthy that clozapine (and possibly other atypical antipsychotics) may also cause neuroleptic malignant syndrome, but the condition may be manifested without rigidity.77

When neuroleptic malignant syndrome is seriously considered, the patient's antipsychotic medication should be discontinued and should not be resumed for at least 2 weeks after resolution of the episode of neuroleptic malignant syndrome.78 Intravenous benzodiazepines should be tried in the interim, given the substantial syndromal overlap between catatonia and neuroleptic malignant syndrome and the unresolved nosology of the two conditions.79–82 The role of dopamine agonists (such as amantadine or bromocriptine) remains unresolved, but amantadine or bromocriptine should be tried.83 The rationale for the use of dantrolene is weak, as is its empirical basis. It is noteworthy that in one small prospective study, the use of dantrolene and/or bromocriptine led to a delayed clearing of the syndrome, possibly by interfering with its natural course.83 Moreover, dantrolene is potentially hepatotoxic, further limiting its usefulness.

General aspects of the management of neuroleptic malignant syndrome are cooling, hydration, prevention of thromboembolism, prevention of complications due to inanition, and prevention of contractures. Aggressive physical therapy needs to be pursued regardless of the patient's mental state, especially if neuroleptic malignant syndrome does not resolve within 2 weeks. Meticulous supportive measures make a difference in the outcome.

Psychogenic polydipsia and hyponatremia syndrome can be an incidental finding in chronic schizophrenia, or it can be the cause of the admission (e.g., hyponatremia-induced confusion or seizures). This condition is not uncommon in patients with chronic schizophrenia; approximately 10% may be afflicted.84 An awareness of its frequency and clinical features are key. Treatment is usually uncomplicated in the general hospital, with patients responding to behavioral interventions (e.g., water restriction) within 24 hours. Some patients may be more difficult to treat because of drinking from toilets. Nursing staff should be made aware of this condition and should monitor fluid intake.85 Even in patients known to suffer from this condition, it is worthwhile to consider other causes of water imbalance, such as drug-induced hyponatremia. Potential culprits include carbamazepine86 and SSRIs. SSRI-induced hyponatremia is more common than previously thought, particularly in elderly patients, among whom one in four cases of hyponatremia may be related to SSRI.87 If an SSRI is not clearly indicated in the management of a patient with schizophrenia, the SSRI should be stopped in cases of psychogenic polydipsia and hyponatremia syndrome. Smoking is another recognized risk factor for hyponatremia.88 If the condition appears refractory to the usual interventions, demeclocycline can be tried,89 or a trial of clozapine may be initiated.90 The pathophysiology of psychogenic polydipsia and hyponatremia syndrome has been reviewed by Goldman and associates91–93 and by Siegel et al..94 It is worth remembering that massive amounts of water are usually required to overwhelm the body's water regulatory system. In psychiatric patients who develop polydipsia and hyponatremia, there appear to be subtle deficits at multiple sites in this system, rendering these patients more vulnerable to water intoxication.93

"The patient is off medications."
Few things instill more fear in medical or surgical house officers than a patient with schizophrenia who has not been taking his or her antipsychotic medication. Often, the consultation is requested with the goal of restarting the antipsychotic medication, even if the patient is sedated (e.g., with propofol) in the intensive care unit.

Several points about the natural course of schizophrenia are worth emphasizing to the medical/surgical team. First, schizophrenia is a lifelong disorder. Most patients have long periods when they are relatively symptom-free (especially from positive symptoms). Even if a stabilized patient discontinues his or her antipsychotic, the time to relapse is usually measured in weeks rather than hours or days. Sudden relapse is rare. Moreover, relapse progresses through stages that give ample warning.95,96 Intervention becomes possible if one recognizes the relapse prodrome, particularly worsening psychosis with poor sleep and anxiety.97 If it appears that a patient's psychosis is worsening, a trial of supplemental benzodiazepines (such as diazepam) might help stave off full syndromal relapse.98 Most hospitalizations are short enough that in the vast majority of cases nothing adverse is likely to happen if the patient does not take a prescribed psychotropic during the hospital stay. The most important concern is to complete the medical/ surgical intervention. A thoughtful review of medications should help in deciding which ones to hold and which ones to restart (in order to avoid withdrawal effects).

Applicable maxim: Recognize when the specter of "imminent decompensation" is raised.

"This patient wants to leave against medical advice. He can't smoke."
Nicotine dependence deserves special mention, as "no smoking" policies are an area of contention for hospitalized smokers.99,100 This is particularly true for patients with schizophrenia, who, as a group, are more likely to smoke and to be heavy smokers, compared to those without schizophrenia.101 Apart from its health-related effects, smoking affects the metabolism of many psychotropics. The tar products in cigarettes (and not the nicotine itself) are inducers of the P450 isoenzyme 1A2.102 Enforced abstinence could in theory lead to increased drug levels for medications metabolized through this isoenzyme. This effect is likely to be relevant only for long hospitalizations, as the "rebound" of the system (like the induction) takes several weeks. In those cases, drug toxicity (e.g., for clozapine) can develop.103 In general, the 1A2 system is "revved up" in smokers, and higher doses of medications metabolized through the P450 system (such as haloperidol) are required for smokers than for nonsmokers.104 In addition, smoking seems to contribute to hyponatremia.88

Several of the patients seen in our psychiatric consultation service wanted to sign out of the hospital because of smoking bans. A flexible approach to this problem usually worked: as unprofessional as this might seem, accompanying a patient for a smoking break went a long way. The patient felt supported and was able to stay in the hospital and receive the needed surgical intervention. An overly restrictive or legalistic view of the problem can thwart the provision of necessary care. Patients in the precontemplation phase of smoking cessation are not likely to quit just because a physician makes the recommendation. Advocacy "for" smoking is indicated for the precontemplative and/or "incompetent" patient who critically needs acute medical care. This said, reducing smoking rates in schizophrenia is an important goal, because smoking contributes to the excess mortality among patients with this disorder.105 Smoking cessation is possible in this population,106 and a medical or surgical hospitalization is a good starting point to motivate a patient for the next step. The nicotine patch or nicotine gum should be offered during the hospitalization for relief from nicotine withdrawal but not necessarily to aid in smoking cessation.107

Applicable maxim: Unconventional interventions are sometimes necessary.


  CONCLUSIONS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 REASONS FOR CONSULTATION AND...
 CONCLUSIONS
Appendix 1: Maxims for...
 REFERENCES
 
The role of the consultation psychiatrist in the general hospital is by necessity often threefold: conducting conventional consultations, educating staff about the nature of schizophrenia, and serving as a physician for the mentally ill. We have provided references for commonly encountered problems in this population and framed issues that interfere with satisfactory care. Good care suffers when fear of the unknown predominates. Consultation psychiatrists can alleviate some of these fears by providing education about the natural course of the illness and about effective interventions and by offering assurance. Patients with schizophrenia also have disease-related factors that limit their ability to participate in their medical care. In addition, patients with schizophrenia are disadvantaged and may not be strong advocates for their care. The consultation psychiatrist should be mindful of obtaining a medical workup for the patient before transfer to a psychiatric facility is necessary.

Even though we have focused on problems associated with psychotic illness, most patients with schizophrenia are psychiatrically stable in the general hospital. The structured hospital environment and the "no-nonsense care" and ward routine seem to be protective rather than stressful for patients with schizophrenia.

In summary, mens sana in corpore sano is as true for patients with schizophrenia as it is for those without schizophrenia. In that spirit, the medical care of patients with schizophrenia should not differ from the medical care of other patients.


  Appendix 1: Maxims for the Consultation Psychiatrist Regarding the Care of Patients With Schizophrenia in the General Hospital

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 REASONS FOR CONSULTATION AND...
 CONCLUSIONS
 Appendix 1: Maxims for...
REFERENCES
 
Recognize that the word "schizophrenia" evokes fear in the heart of staff members.

Expect that patients with schizophrenia are perceived as "irrational," "oppositional," and "lazy."

It is twice as difficult for psychiatric patients to appear half as normal.

Develop a differential diagnosis of "depression."

Being "crazy" (psychotic) does not mean that the patient is "stupid" (incompetent).

Carefully review polypharmacy.

Consider yourself the patient's only physician.

Respect psychotic thinking.

Respect powerful psychotropic medications.

Recognize when the specter of "imminent decompensation" is raised.

Unconventional interventions are sometimes necessary.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 REASONS FOR CONSULTATION AND...
 CONCLUSIONS
 Appendix 1: Maxims for...
 REFERENCES
 

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