Schizophrenia – pre-empting the 30-days policy

Readmission to hospital within 30 days of discharge already incurs financial penalties for hospitals in certain areas of medicine, for example, coronary heart disease and chronic obstructive pulmonary disease. Currently, such a policy is not implemented in psychiatric medicine but Dr Alisa Busch, Harvard University, Boston, MA, was interested to see what drives readmission in patients with schizophrenia.

Using the patient records of adult, non-elderly patients with schizophrenia receiving Medicaid, the Complete Claims Data from 18 States and the US Health Resource File, Dr Busch used two regression models, the first looking at patient characteristics and the second relating to county characteristics (i.e. propensity to hospitalization, community-based quality and capacity) to determine what factors were driving readmission tendencies in this patient group.

Co-morbidity was one key determinant of rehospitalisation with substance use disorders (SUD), perhaps unsurprisingly, increasing readmissions by 67%.  General medical conditions, such as diabetes, also contributed significantly to readmission rates.

Regarding community quality and utilization characteristics, only the rate of 7-day post-discharge follow-up and the overall county mental health/SUD hospital rate appeared to drive readmission in patients with schizophrenia – not other community or capacity measurement appeared associated with readmissions, although Dr Bosch suspects this is unlikely to be the case.

The findings of the study highlight the importance of targeted care co-ordination particularly in those patients who present with SUD. New Medicaid rules are about to be introduced that give parity to the treatment of SUD which this may help reduce the rate of readmissions in future. A better understanding the role of provider capacity in 30-day hospitalization is also needed in the future management of patients with schizophrenia.

Glycine reuptake inhibitors – will they or won’t they work in schizophrenia?

The merits of the glutaminergic hypothesis in schizophrenia are widely known. While therapies are available that have begun to address targeting the symptoms associated with this condition, 14-17% of an estimated 26 million schizophrenia sufferers still experience persistent negative symptoms. As Dr Rejish Thomas, University of Alberta, Canada, explained, clearly there is a great need for new therapies. 

The negative symptoms of schizophrenia are thought to arise due to hypofunctioning of N-methyl-D-aspartate (DMDA) glutamate/glycine synapses.  The glutaminergic hypothesis affords many potential targets but currently there are just three drugs in Phase III trials, two of which are glycine re-uptake inhibitors (GRIs).  A thorough review of the literature reveals that while GRIs appear good candidate molecules during preclinical studies, the phase II and III results reported thus far are disappointingly poor.

Nevertheless, despite these setbacks, the promise of GRIs remains. Once psychiatric research yields a better understanding of the underlying pathology of schizophrenia, their role may be better clarified. With further research into biomarkers and the encouragement of a greater emphasis on the development of novel psychopharmaceutical targets, the potential bonanza of other new targets the glutaminergic hypothesis promises may eventually be realised.