Progress, Measured in Increments

Progress, Measured in Increments

Examining the treatment of schizophrenia

This is not a story about a stunning scientific breakthrough or a cure for a debilitating and deadly disease that haunts individuals and families.

No, this is a story about slow, steady, incremental progress. About mitigating symptoms and minimizing side effects; about a long-term battle against a lifetime illness for which a partial reduction in symptoms represents a major victory, and simply convincing patients to take their medication is a constant challenge.

The disease is schizophrenia. It has no cure, and the dysfunctional organ is not the kidney or the colon, but the brain.

In the UMKC School of Pharmacy, faculty researchers Roger W. Sommi, Pharm.D., FCCP, BCPP; and Leigh Anne Nelson, Pharm.D., BCPP; are working to help people living with this disease alleviate their symptoms and reclaim their lives.

Drug therapy for schizophrenia presents multiple challenges that researchers are working to overcome. Drugs are only partially successful at reducing the number and severity of symptoms; they have numerous and often debilitating side effects; and the side effects combine with delusional and cognitive symptoms to make even basic adherence — taking your medication every
day — a struggle.

“With medication, on a good day, you might see an average of 70 percent of symptoms relieved,” Sommi says.

The price of that progress is both metabolic and neurologic side effects. The former includes weight gain, increased cholesterol levels and higher risk of diabetes; the latter, abnormal involuntary movements that can be embarrassing and stigmatizing.

It should come as no surprise, then, that according to one of the multicenter studies conducted at the UMKC site, 75 percent of patients stop taking their medication during the course of 18 months of treatment.

Much of the research, therefore, focuses on either reducing side effects or finding ways to increase adherence with the medication regimen.

“The side effects are not pleasant. Newer medications have tried to make them a little more tolerable,” says Sommi, a professor of pharmacy practice and administration and psychiatry. A member of the UMKC faculty for 31 years, Sommi says that while getting patients to take their medication regularly remains a major challenge, successes in that area can produce a significant improvement in the quality of life for patients.

One area of progress has been changing the formulation of existing antipsychotic drugs — for example, replacing traditional pills with fast-dissolving oral medications or long-acting injectables. Hospitalized patients often become skilled at hiding a standard pill in a cheek while pretending to swallow, then spitting the drug out later. A fast-dissolving tablet makes that more difficult.

Long-acting injectable antipsychotics replace daily pills with injections that can last anywhere from two weeks to three months. In trials, these new formats have reduced relapse rates and kept patients out of the hospital for longer periods.

“We’re really hoping we can move the relapse and recovery needle with these drugs,” Sommi says.

Nelson, a UMKC School of Pharmacy alumna who has been on faculty since 2005, says medication adherence can have huge impacts.

“We can get patients back into high school, back into college, see them become employed, get them to be functional in society,” she says.

She participated in a five-year National Institute of Mental Health study of young people recovering from their first episode of schizophrenia. The key finding: “We can make a big impact on a young person if we can get them to adhere to their medication schedule and give them some insight into their disease state.”

Another key reason to promote adherence: Relapse or episodes of acute psychosis destroy brain cells by over-exciting them.

“The more time people spend sick, the more they lose,” Sommi says.

Still, progress is measured in increments. A multicenter study done here at UMKC looking at the impact of long-acting injectable antipsychotics, for example, shows that people with schizophrenia released from jail who receive these medications have, on average, one fewer re-incarceration per year than those treated with pills.

Better, but not a breakthrough.

“There’s always hope,” Sommi says. All of the drugs currently
prescribed for schizophrenia work on the same basic premise: adjusting the mix of brain chemicals — neurotransmitters — that govern brain function. These drugs reduce brain chemistry to a simple equation, he says; too much dopamine, too much serotonin.

“But it’s not that simple. The brain is a very complex organ,” Sommi says. “The taxonomy for psychiatric illnesses we have now is really inadequate in terms of predicting who will respond to what drug. We make the decision based on matching the side effects profile of a given drug to the risks the patient has for those side effects. The patients often feel like guinea pigs because we keep trying different things.”

Now, researchers such as Nelson and Sommi are looking down alternative pathways. Both are long-term leaders in the College of Psychiatric and Neurologic Pharmacists. Nelson is a current board
member, Sommi a past president.

“We’re looking for things that challenge the neurotransmitter-based approach,” Sommi says. “If we can understand better how people develop schizophrenia — the genetic basis — that could lead to more
precise diagnosis and treatment.”