The general goals for recovery of patients with schizophrenia are relatively simple: to improve patients' functioning, enable them to return to work or school, and allow them resume normal lives. However, there are differences between inpatient and outpatient treatment as it relates to some of these goals. For example, a hospitalized patient who has just suffered an acute episode may not be able to realistically meet the abovementioned goals. In such cases, clinicians must try to meet more feasible goals: moving patients from an acute episode to remission, reducing symptoms, improving function, and achieving stability outside of the hospital (Slide 1). This road to recovery involves two phases of treatment, inpatient and outpatient, which differ in their pursuit of patient stability. This discussion will touch on some of the differences between inpatient and outpatient treatment as it relates to acute goals and successful long-term treatment.

Recognizing drug-drug interactions (DDIs) has become increasingly important as the country's demographics have aged, resulting in more complex medication regimens. Budnitz and colleagues highlighted the frequency of adverse drug reactions (ADRs) and the substantial morbidity that results. Their study estimated >700,000 cases of ADRs in emergency rooms (ER) in the United States between 2004 and 2005, and that ADRs accounted for 6.7% of ER visits for unintentional injuries that led to hospitalization. Moreover, medications that require monitoring accounted for 41.5% of all the ADR-related hospitalizations.

These data have tremendous implications for the field of psychiatry because many psychiatric drugs require therapeutic monitoring. The importance of DDIs is particularly relevant for the psychiatric population, where adverse effects not only cause short-term morbidity, but may lead to long-term treatment noncompliance. For many patients taking antipsychotics, adherence is the key to a successful outcome. Minimizing DDIs maximizes the chance that people will avoid unnecessary ADRs while achieving therapeutic drug levels.

Antipsychotics have become the cornerstone of management for many severe mental disorders. Primarily developed for the treatment of schizophrenia, several antipsychotics have been indicated for bipolar mania, bipolar depression, and irritability associated with autistic disorder. Antipsychotics are also used off label for psychotic or refractory depression; refractory anxiety disorders; and conditions associated with agitated or aggressive behaviors. Due to the severity and chronicity of severe mental disorders, the broad range of potential treatment targets, and the relative ease of use of second-generation antipsychotics (SGAs), which are associated with a lower risk of extrapyramidal symptoms (EPS) and tardive dyskinesia (TD), prescribing rates have increased considerably over the last decade. With increased utilization of these medications comes a greater responsibility to appropriately recognize, monitor, and manage side-effect clusters that can adversely affect physical and mental outcomes.

Schizophrenia is associated with increased medical comorbidity likely caused by interactions between life-style, environment, and the disease itself. High rates of medical comorbidity exist among all forms of serious mental illness. Affective disorders such as bipolar disorder and unipolar depression are associated with 1.5–2 times the mortality rate observed in the general population, and high rates of HIV and hepatitis A, B, and C exist among patients with severe mental illness. However, schizophrenia is particularly affected by medical comorbidities, and is associated with a 20% shorter-than-normal lifespan. This discussion focuses on rates of medical comorbidity in people with schizophrenia and the effects of medication on cardiometabolic risk factors. It is also important to recognize that lifestyle and environmental factors associated with serious mental illness, as well as poor access to healthcare, contribute to the elevated rates of medical illnesses observed in these populations as well.

Studies of the association between schizophrenia and medical comorbidities have suggested that the introduction of second-generation antipsychotics (SGAs) may be responsible for the increases observed in cardiovascular disease rates in this patient population, and that cardiovascular disease mortality may be shifting to an earlier stage of life. Ösby and colleagues observed that while overall cardiovascular mortality in schizophrenia patients in Sweden increased from 1976–1995, an even greater increase occurred in men from 1991–1995. This latter increase corresponded temporally to an increased use of SGAs.

Osborne and colleagues recently confirmed the observation made by Osby and colleagues. They compared 46,000 people with serious mental illness and a general population sample of ∼300,000 people from 1987–2002.