A key consideration in the discussion of maintenance treatment in schizophrenia is how to first help bring patients to the point where acute psychopathology is sufficiently controlled, so that we can focus on consolidating the gains achieved and prevent a recurrence of illness.
The different phases of treatment and response in schizophrenia include the acute phase, wherein we look for response and resolution; remission, where we control symptoms to levels of mild or less and work toward preventing relapse or any exacerbation of psychopathology; and recovery, meaning the ability to function in the community in the workplace, school, family roles, etc.
In preparing patients with schizophrenia for maintenance treatment, clinicians must ensure that they have done everything possible to alleviate the acute signs and symptoms of illness to the extent possible.
There are several questions to consider at this stage: How much improvement is enough? When do we change treatments, and why? What about adverse effects and the locus of care? In the context of this process of deciding how to bring about the best possible treatment response, we must consider that, if a patient is not responding, the diagnosis may need to be reevaluated. Adherence must be assessed and blood levels should be done (if feasible) to ensure that patients have an adequate amount of medication in their system. If blood levels are unavailable and adherence is an issue, the use of long-acting injectable medication should be considered. The clinician might decide to alterthe medication dose—to increase it, or perhaps decrease it if significant side effects are impeding therapeutic response. Adjunct medications or a switching strategy may be employed. Non-pharmacologic therapy, such as cognitive behavioral therapy, which can be effective at reducing symptoms of schizophrenia, should also be considered.