To address the uncertainty of working with refractory patients in our large forensic hospital system, the California Department of State Hospitals created a psychopharmacology resource network. This network of prescribers, led by the authors of this book, has overcome the isolation experienced by clinicians in our system by developing and communicating best practices beyond previous guidelines. This team has evolved a process of education and consultation by blending the practical application of sophisticated evidence-based knowledge with vast experience in the pharmacological treatment of a very complex and difficult patient population.
The ideal trajectory for an individual who develops a schizophrenia spectrum disorder is early intervention with medication and psychoeducation, followed by close monitoring of optimal psychopharmacology, housing support and vocational therapy. The reality we see is a course of inability to access care, worsening psychotic symptoms, substance abuse, homelessness, and repeated criminal justice contacts as a result of the aforementioned factors. From criminal justice involvement flows trauma, inconsistent psychopharmacology and acquisition of criminogenic risk factors [Reference Warburton1]. From these factors flows aggression, alienation and a deepening of the disenfranchisement that began the cycle. Today’s complex, treatment-resistant patients require interventions at the level of most of these factors. But the cycle can only be broken with appropriate and effective psychopharmacology.
The goal of the authors is to further widen the network of prescribers working in the most challenging psychiatric environments with the most challenging patients. The authors attempt this by presenting systematic treatment strategies based on current evidence and extensive experience. The focus will be on those medications and strategies they’ve found especially useful in treating treatment-resistant, severe psychotic illness.
In Chapter 1, approaches to positive psychotic symptoms are explored with straightforward algorithms. In Chapter 2, the authors share the necessity and utility of plasma drug levels in guiding psychopharmacological intervention. Chapter 3 discusses the advantages of using long-acting injectable antipsychotic medication and provides useful initiation strategies. Chapter 4 takes a deep dive into the concept of treatment resistance and reviews the evidence for various strategies. Chapter 5 discusses strategies for working with depressed or suicidal patients who are also living with schizophrenia spectrum disorders. Chapter 6 is an overview of how to address aggression in this population. Chapter 7 addresses the approach to bipolar diathesis in schizophrenia. Chapter 8 provides guidance when an individual living with schizophrenia is also suffering from anxiety. Chapter 9 focuses on sleep disturbances. Psychosis in children and adolescents is addressed in Chapter 10. Chapter 11 is an exploration of electroconvulsive therapy, along with other non-pharmacological treatments in this select patient population. Chapter 12 describes how to approach substance use disorders among these patients. Part I rounds out with strategies to mitigate behavioral disturbances, as well as how to address dementia and traumatic brain injury.
Part II of this book provides a practical and easy to follow prescribers guide for the agents discussed throughout the book based upon the well-known format used in Dr. Stahl’s best-selling psychopharmacology prescribers guide [Reference Stahl2]. Part III of the book provides further reference material on everything from how to manage constipation to how to load medications.
I am humbled and grateful for the work our psychopharmacology team has done to standardize and improve the care of our most complex, treatment-resistant patients. They have found methodologies to approach patients previously thought to be impossible to treat. I am confident the reader will benefit from the knowledge and experience reflected in this book and will join our network of clinical expertise.
