Recent announcements by the Centers for Medicare & Medicaid Services (CMS) state its suspicions that a significant number of minimum data set (MDS) diagnoses of schizophrenia were made for the wrong reasons, creating fear and defensiveness on the part of the industry.
Schizophrenia is a serious diagnosis. The initial onset of symptoms usually occurs in the late teens through the early 30s. Symptoms usually represent fairly sudden and dramatic changes, often characterized by auditory or visual hallucinations; frightening delusions causing paranoia and fear; a new inability to take care of oneself in some of the simplest ways, such as bathing, dressing, and basic hygiene; and an inability to think or speak clearly. This break with reality can be terrifying for the person having the experience and confusing for loved ones.
New onset of schizophrenia often results in a first hospitalization followed by experimenting with medications in an effort to regain stability and control of one’s life. While it frequently requires trial and error, that newfound stability also feels precarious, and medication changes can return the patient to a crisis state if they are not handled carefully. This is the reason that schizophrenia was listed as one of the three diagnoses that did not require at least quarterly review and attempts to adjust medications to the lowest level needed to maintain stability without the high risk of life-changing side effects.
Who would have thought this appropriate exception would have been used to make the complicated process of gradual dose reduction and management of psychotropic medications seem unnecessary and avoidable? But, according to CMS, that is exactly what happened, and it has every intention of uncovering any illegitimate claims and invoking consequences, which can be painful for offending providers.
With these new developments in mind, how can we ensure accurate identification and diagnosis of schizophrenia as a foundation for proper care and management? Here’s a basic guide:
Do Your Due Diligence
Find out when the first onset of symptoms occurred and what they looked like. Through interviews with the patient, family members, or a thorough review of the medical record, the patient’s experience can be illustrated. This is important for several reasons. First, to create a record that shows the individual has been diagnosed by a professional based on specific events. Second, to provide you with a picture of what may happen if your patient destabilizes, what warning signs or triggers you may need to be aware of. This can be included in your behavior monitoring tools to keep record of potentially high-risk behavior. Third, to provide potential insight into how medications have been tried, failed, or succeeded in your patient’s past. This can circumvent some of the trial and error that often accompanies a destabilization event.
Pull that Neuropsychiatric Evaluation
Schizophrenia is difficult to diagnose. For some people, it may be disconnected thinking that leads to strange conversations, failing scores at school, or nonsensical discourse. Such changes should be brought to the attention of a psychiatrist or other mental health professional to identify and diagnose the new onset of illness and begin the process of behavior control through medication. If you cannot find a record, be sure to ask. Family will often know who made the diagnosis. That record will provide important support for your conclusion. If there is no record, it’s time to see a professional.
Look at Medication History
What has been tried and how well did it work? As you play a role in maintaining the patient’s stability, this information can be vital to success. Remember, unsuccessful management of schizophrenia means your patient is likely to be truly suffering. If you can imagine yourself having the symptoms described above, you may be able to glimpse how distress, confusion, fear, and shame would all play a part.
Track Side Effects
One of the biggest issues with the use of psychotropics, especially antipsychotic medications, is the potential side effects. These extrapyramidal effects can, unfortunately, be permanent once they begin. Facial or verbal ticks, changes in proprioception and balance, and other obvious physical changes may occur and progress quickly and may not be reversible. Knowing these risks and observing for them can make the difference between careful management and a radical change for the patient. Performing that baseline Abnormal Involuntary Movement Scale (AIMS) assessment and repeating it every six months of medication use can make the difference by providing early recognition that things are changing.
Document Everything
Pulling together the big picture and maintaining a clear record is essential to managing your patient’s illness and supporting your diagnosis. The psychiatric evaluation, the trial and decisions around medication management, the symptoms that alert your team that the illness is not well-managed, and the ongoing monitoring for negative response to medications—all together—provide full support for your work and ensure the best management for your patient.
Late Onset Schizophrenia
New information supports the fact that a person may experience their first schizophrenia symptoms over the age of 45. Late onset symptomology is more likely to be hallucinations, delusions, and truly disorganized thinking. Less subtle than the early onset experience, late onset schizophrenia can be triggered by genetics, neurological changes, or events. Either way, it becomes a life-changing experience that will require skillful management. A thorough neuropsychiatric evaluation is essential and offers the best opportunity to get your patient the help they need to live a full and meaningful life.
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