Treatment Options and Managing Side Effects in Schizophrenia

In this live Q&A recorded at Psych Congress Elevate, Psych Congress Network's Schizophrenia Section Editor Leslie L. Citrome, MD, MPH, clinical professor of psychiatry and behavioral Sciences, New York Medical College; Rebecca Kraus, MSPAS, PA-C, physician assistant, Southlake Psychiatry; and Bethany Yeiser, BS, president, CURESZ Foundation, Fairfield, Ohio, answer questions about treating schizophrenia, including the strengths and limits of electroconvulsive therapy (ECT), what makes clozapine so effective, and managing sedation as a side effect.

Andrew D. Penn, MS, PMHNP, associate clinical professor, School of Nursing, University of California, San Francisco, moderated the Q&A session that followed the panel entitled "TAAR1 Agonism: A Novel Approach to Schizophrenia Management."

Scroll down to read the transcript of this podcast.

Listen to Part 1: How TAAR1 Agonists Might Be Used in Schizophrenia Treatment here!

Leslie Citrome, MD, MPH, is clinical professor of psychiatry and behavioral sciences at New York Medical College in Valhalla, New York, and adjunct clinical professor of psychiatry, Icahn School of Medicine at Mount Sinai in New York City, New York. In addition to his academic positions, he has a private practice in psychiatry in Pomona, New York. He is a Distinguished Life Fellow of the American Psychiatric Association and a Fellow of the American Society of Clinical Psychopharmacology where he currently serves as President.

Dr Citrome earned his medical degree from McGill University in Montreal, Canada, and his master’s degree in public health from the Columbia University School of Public Health, Division of Health Policy and Management in New York, New York.

Dr Citrome is a consultant in clinical trial design and interpretation. He is a frequent lecturer on the quantitative assessment of clinical trial results and has lectured throughout the United States, Canada, Europe, and Asia. His main interests include schizophrenia, bipolar disorder, and major depressive disorder. He is author or coauthor of over 500 research reports, reviews, and chapters in the scientific literature. Dr Citrome is editor emeritus of the International Journal of Clinical Practice and is on the editorial boards of several publications, including the Journal of Clinical Psychopharmacology, CNS Spectrums, Clinical Psychopharmacology and Neuroscience, and Expert Review of Neurotherapeutics.

Rebecca Kraus, MSPAS, PA-C, earned a Master’s Degree in Physician Assistant Studies from the University of Kentucky in 2012. A recommendation from a classmate and a whim took her to Charlotte, NC where she started her career as a PA-C in Neuropsychiatry. This is where she developed her passion for patient care and psychopharmacology. She has been at Southlake Psychiatry in Davidson, North Carolina since 2016, where she maintains full-time practice treating children, teens, and adults in the outpatient setting. She also underwent Buprenorphine training to provide medication assisted treatment for opioid dependence. She enjoys treating the full spectrum of psychiatric disorders including depression, anxiety, bipolar disorder, schizophrenia, obsessive compulsive disorders, gender dysphoria, eating disorders, and post traumatic stress disorders.

Bethany Yeiser, BS, serves as President of the CURESZ Foundation which she co-founded with Dr. Henry Nasrallah in 2016. CURESZ stands for Comprehensive Understanding via Research and Education into SchiZophrenia. She also works as an author and mental health advocate. Her memoir Mind Estranged (2014) follows her trajectory from the onset of mental illness, through acute psychosis, homelessness, two brief incarcerations, and full recovery.

As a motivational speaker, Bethany inspires positive change in the way people diagnosed with schizophrenia are characterized and treated in the health care system and by society. She discusses strategies for effective teamwork among families and health care providers, helping patients develop insight into mental illness, consent to treatment, and achieve the highest possible level of recovery. Bethany also raises awareness of the disproportionately high rate of incarceration of the mentally ill. Bethany holds a bachelor’s degree in molecular biology with honor from the University of Cincinnati. She maintains a blog called Recovery Road on PsychologyToday.com. Her other interests include performing classical and popular music on violin, and studying ancient Hebrew and Mandarin Chinese.

Andrew Penn, MS, PMHNP, was trained as an adult nurse practitioner and psychiatric clinical nurse specialist at the University of California, San Francisco. He is board certified as an adult nurse practitioner and psychiatric nurse practitioner by the American Nurses Credentialing Center. He has completed extensive training in Psychedelic Assisted Psychotherapy at the California Institute for Integral Studies and has published in the American Journal of Nursing, Bipolar Disorders, and Frontiers in Psychiatry. He was a study therapist on the MAPS-sponsored Phase 3 study of MDMA assisted psychotherapy for PTSD and is currently a co-investigator on the Usona-sponsored phase 2 study of psilocybin facilitated therapy or major depression.

Currently, he serves as an Associate Clinical Professor at the University of California-San Francisco School of Nursing where he teaches psychopharmacology and is an Attending Nurse Practitioner at the San Francisco Veterans Administration with the joint UCSF/SFVA NP residency program. He has expertise in psychopharmacological treatment for adult patients and specializes in the treatment of affective disorders and PTSD. He has published on the risks and benefits of cannabinoids in psychiatric treatment.

As a steering committee member for Psych Congress, he has been invited to present internationally on improving medication adherence, cannabis pharmacology, psychedelic assisted psychotherapy, grief psychotherapy, treatment-resistant depression, diagnosis and treatment of bipolar disorder, and the art and science of psychopharmacologic practice. In 2021, he was awarded the Distinction in Teaching Award by the UCSF Academic Senate.

Read the Transcript:

Andrew Penn: Mm-hmm (affirmat ive). There's a number of questions around refractory schizophrenia. So where does ECT, TMS fit into all of this. Asking Bethany, if you ever had ECT and if you did, what your experience was with that?

Bethany Yeiser: If I had ACT?

Andrew Penn: ECT. Electroconsulvise--

Bethany Yeiser: Oh no, I've never had ECT, I see it occasionally in patients and families that contact the cures foundation. I understand it's used more commonly in depression.

Andrew Penn: Uh-huh (affirmative).

Leslie Citrome: Although I have to say, ECT had been my go-to when I worked for the state hospital system in New York for many years. I ran an inpatient research and evaluation unit. We would have patients, lots of patients, on clozapine actually. Lots and lots. It's probably the antipsychotic I have the most experience with, but it doesn't doesn't work with everybody. And it may dial down some of the symptoms, but there may be still some troubling symptoms that are difficult to get a handle on, including aggressivity. And ECT combined with clozapine has been very helpful.

Andrew Penn: Yeah.

Leslie Citrome: It's difficult to study because sham ECT is difficult to actually do. But the effect size is pretty large. When you look at the data that's available out there and it is a standard of care, you do think about ECT added onto clozapine when you've run out of other options.

Andrew Penn: Right. And what is it about clozapine that makes it so effective? Because when you look at binding profile, it's not that potent on D2--

Leslie Citrome: Right. It has very low binding to dopamine D2 receptors, not the lowest mind you, there's another agent out there that has even a lower occupancy of dopamine D2, but it still works.

Andrew Penn: Yeah.

Leslie Citrome: So, but it, that's probably not how it does its main work. There's been some speculation, that it is a glycine transport inhibitor. So there's data showing that. And it also is a muscarinic modulator as well. And so there's a whole host of studies being done now of potential treatment of schizophrenia with modulation of muscarinic receptors.

Andrew Penn: Okay. There's some questions about side effect management, Bethany referring to your mention of armodafinil I think you said, or modafinil-

Bethany Yeiser: I take armodafinil. I took modafinil for a couple years and switched to armodafinil.

Andrew Penn: Yeah. And is that something that you see frequently prescribed to address some of the sedating side effects of antipsychotics?

Bethany Yeiser: I frequently run into patients and families for the CURESZ foundation where the loved one is, they say, sedated all the time, feeling like a zombie, sleeping many hours and will have a conversation about armodafinil. But yeah, some of these off-label drugs for schizophrenia and schizophrenia antipsychotic side effects are highly effective.

Rebecca Kraus: Sometimes you have to get creative when you find something that works for your patient. And it's that clear, like in Bethany's case, after you started to clozapine the difference, and you know, that's what her brain is needing. Sometimes you have to get creative to try to tackle those side effects.

Andrew Penn: Yeah.

Leslie Citrome: Especially if someone is receiving clozapine. Because they're receiving clozapine for a reason and it's not something, oh, I'll just switch it to something else, because there is no equivalent to clozapine. So you'll work with whatever the adverse events of clozapine are and try to mitigate them as best you can. And then you turn to more creative solutions for that. Like armodafinil.

Andrew Penn: Yeah. I know we're up against the time here, but I just want to synthesize some, a few things that were said towards you, Bethany around just really appreciating your introduction of the idea of recovery into this and hearing your story about what you first heard when you were diagnosed with this. And then what you discovered working with Dr. Nasral made me think that with schizophrenia, I think often we have low expectations for our patients' recovery and that needs to change. And that we as clinicians often have low expectations of ourselves and that needs to change too, that we need to do better. And I hope that your story here today and which you've provided by way of education really serves to inspire us.

Bethany Yeiser: Thank you. I hope you will choose to never lower your expectations with patients, to do everything in your power to get them in the highest quality of life possible.

Andrew Penn: Well, that's a good note to end on.

Rebecca Kraus: Yes.

(applause)