Psychiatric Annals

NURSING HOME PSYCHIATRY 

Schizophrenia in Nursing Home Patients

J Steven Lamberti, MD; Pierre N Tariot, MD

Abstract

Schizophrenia is a severe mental illness affecting 1% of all adults. Because of the often devastating impact of this illness, a significant percentage of patients with schizophrenia receive long-term institutional care. While this care has traditionally been provided by state psychiatric hospitals, recent decades have witnessed the "transinstitutionalization" of many older psychiatric patients into nursing homes. In addition to changes in long-term care delivery, it has been estimated that 20% of all adults will be over age 65 by the year 2030. l These factors have resulted in nursing homes managing increasingly large numbers of patients with schizophrenia in recent years. This trend poses special challenges to nursing home staff and underscores the importance of understanding both the impact of schizophrenia in late life and the special needs of this population.

COURSE OF SCHIZOPHRENIA IN LATE LIFE

Data about the natural history and outcome of schizophrenia is seriously limited because most follow-up studies were conducted prior to the introduction of DSM-III. These studies probably included patients who would receive diagnoses of schizophreniform disorder, delusional disorder, or biopolar disorder using modern diagnostic criteria. In addition, most studies of schizophrenia and aging did not examine those patients whose initial episode occurred in middle or late life.2 Despite these limitations, existing studies challenge the traditional notion that schizophrenia has an invariably deteriorating course (Table 1). Recent reviews of the long-term outcome literature have revealed a number of important observations3,4:

* Long-term outcome of schizophrenia is characterized by enormous variability, with many patients showing marked improvement.

* Deterioration in schizophrenia usually occurs around the onset of illness, and is often limited to the first 5 or 10 years of illness.

* Positive symptoms tend to improve with age, while negative symptoms appear to become more disabling in late life.

* Overall mortality is higher for patients with schizophrenia than for the general population.

Predictors of favorable outcome of schizophrenia in late life remain uncertain. While standard prognosticators such as good premorbid functioning, acute onset, and lack of negative symptoms are probably important, duration of illness may be an especially crucial predictor.4 It is important to note that a number of psychosocial factors, including life events, social supports, and coping skills, are likely to influence the long-term course and outcome, although the roles of such factors have not been adequately studied.5

EPIDEMIOLOGY

The prevalence of schizophrenia in nursing homes is currently unknown, but growing evidence suggests that patients with schizophrenia comprise a significant proportion of all nursing home residents. Even before deinstitutionalization of large numbers of psychiatric patients from state hospitals, studies indicated that many nursing home residents suffered from serious mental illness.6 Most early studies, however, suffered from lack of standardized psychiatric interview procedures and reliance on chart diagnoses. Three recent cross-sectional studies (summarized in Table 2) have avoided these problems by performing actual psychiatric evaluations of nursing home residents.7"9 These studies indicate that a vast majority of nursing home residents suffer from some neuropsychiatrie disorder and that up to 12% suffer from schizophrenia or other primary psychotic disorder. Review of these data also suggests that public nursing homes are more likely than private facilities to accept patients from state psychiatric hospitals and that many of these patients have chronic schizophrenia.

Table

These findings may not be generalizable to other nursing homes because Monroe Community Hospital has a close working relationship with an academic medical center and a full-time consultation service. Most nursing homes are known to have extremely limited psychiatric services on site (C.A. Podgorski et al, unpublished data, 1990). The consultation service at Monroe Community Hospital allows complex problems to be managed…

Schizophrenia is a severe mental illness affecting 1% of all adults. Because of the often devastating impact of this illness, a significant percentage of patients with schizophrenia receive long-term institutional care. While this care has traditionally been provided by state psychiatric hospitals, recent decades have witnessed the "transinstitutionalization" of many older psychiatric patients into nursing homes. In addition to changes in long-term care delivery, it has been estimated that 20% of all adults will be over age 65 by the year 2030. l These factors have resulted in nursing homes managing increasingly large numbers of patients with schizophrenia in recent years. This trend poses special challenges to nursing home staff and underscores the importance of understanding both the impact of schizophrenia in late life and the special needs of this population.

COURSE OF SCHIZOPHRENIA IN LATE LIFE

Data about the natural history and outcome of schizophrenia is seriously limited because most follow-up studies were conducted prior to the introduction of DSM-III. These studies probably included patients who would receive diagnoses of schizophreniform disorder, delusional disorder, or biopolar disorder using modern diagnostic criteria. In addition, most studies of schizophrenia and aging did not examine those patients whose initial episode occurred in middle or late life.2 Despite these limitations, existing studies challenge the traditional notion that schizophrenia has an invariably deteriorating course (Table 1). Recent reviews of the long-term outcome literature have revealed a number of important observations3,4:

* Long-term outcome of schizophrenia is characterized by enormous variability, with many patients showing marked improvement.

* Deterioration in schizophrenia usually occurs around the onset of illness, and is often limited to the first 5 or 10 years of illness.

* Positive symptoms tend to improve with age, while negative symptoms appear to become more disabling in late life.

* Overall mortality is higher for patients with schizophrenia than for the general population.

Predictors of favorable outcome of schizophrenia in late life remain uncertain. While standard prognosticators such as good premorbid functioning, acute onset, and lack of negative symptoms are probably important, duration of illness may be an especially crucial predictor.4 It is important to note that a number of psychosocial factors, including life events, social supports, and coping skills, are likely to influence the long-term course and outcome, although the roles of such factors have not been adequately studied.5

EPIDEMIOLOGY

The prevalence of schizophrenia in nursing homes is currently unknown, but growing evidence suggests that patients with schizophrenia comprise a significant proportion of all nursing home residents. Even before deinstitutionalization of large numbers of psychiatric patients from state hospitals, studies indicated that many nursing home residents suffered from serious mental illness.6 Most early studies, however, suffered from lack of standardized psychiatric interview procedures and reliance on chart diagnoses. Three recent cross-sectional studies (summarized in Table 2) have avoided these problems by performing actual psychiatric evaluations of nursing home residents.7"9 These studies indicate that a vast majority of nursing home residents suffer from some neuropsychiatrie disorder and that up to 12% suffer from schizophrenia or other primary psychotic disorder. Review of these data also suggests that public nursing homes are more likely than private facilities to accept patients from state psychiatric hospitals and that many of these patients have chronic schizophrenia.

Table

TABLE 1Long-Term Outcome Studies of Schizophrenia (Stable End-States Over 5 Years)

TABLE 1

Long-Term Outcome Studies of Schizophrenia (Stable End-States Over 5 Years)

Table

TABLE 2Summary of Modern Prevalence Studies

TABLE 2

Summary of Modern Prevalence Studies

DIAGNOSIS

The presence of psychotic symptoms in nursing home residents can pose a diagnostic challenge. In order to accurately diagnose schizophrenia, a careful assessment of presenting symptoms and their course over time is required. Diagnostic criteria listed in DSMIV10 include:

1. The presence of at least two characteristic symptoms during a 1-month period, such as hallucinations, delusions, disorganized speech or behavior, and negative symptoms.

2. Significant social or occupational dysfunction following onset of the illness.

3. Continuous signs of the illness for at least 6 months.

4. Exclusion of substances or general medical conditions as possible causative agents.

Because schizophrenia typically begins during young adulthood, patients with schizophrenia in nursing home settings may present with long and well-documented histories of illness. Many nursing home residents, however, will present with a new onset of psychotic symptoms in late life. The new onset of psychosis in a previously asymptomatic nursing home resident always requires a very careful diagnostic evaluation. Such an evaluation should consist of a thorough history and physical examination, a complete laboratory evaluation including a toxicology screen, an EKG, a chest x-ray, and a magnetic resonance or computed tomography scan. Accurate diagnosis of schizophrenia rests on the clinician's ability to rule out other possible causes of psychosis because schizophrenia lacks pathognomonic signs or characteristic x-ray and laboratory findings. Many medical and neurological disorders can present with psychotic symptoms in late life, some of which are listed in Table 3.

The issue of whether schizophrenia can first begin in late life remains somewhat controversial. Although a significant majority of cases of late-onset psychosis are due to wellrecognized medical or neurological disorders, a growing body of literature has documented the occurrence of late-onset psychosis in the absence of such disorders.11"14 Subtle brain changes resembling those found in early-onset schizophrenia are sometimes found in these patients, including increased third ventricular size and increased caudate D2 receptor density.12

Table

TABLE 3Common Causes of Psychotic Symptoms in the Elderly

TABLE 3

Common Causes of Psychotic Symptoms in the Elderly

Many different terms have been used to describe the new onset of psychosis in late life, such as paraphrenia, senile schizophrenia, and late-onset schizophrenia. While schizophrenia is generally viewed as a disease affecting young adults, DSM-IV now states that "Schizophrenia can also begin later in life (e.g., after 45 years). Late-onset cases tend to be similar to earlier-onset schizophrenia, except for a higher ratio of women, a better occupational history, and a greater frequency of having been married." Compared to early-onset schizophrenia, studies examining the clinical presentation of late-onset schizophrenia have also reported fewer negative symptoms and a higher frequency of sensory deficits.15-17

Considerable diagnostic overlap exists between late-onset schizophrenia and delusional disorder, which also has its onset in middle to late adult life. However, it should be noted that DSM-IV criteria for delusional disorder specify the presence ofnonbizzare delusions, of tactile or olfactory hallucinations that are related to the delusional theme, and of no marked impairment in psychosocial functioning.

USE OF PSYCHIATRIC SERVICES

The psychiatric needs of patients with schizophrenia in nursing homes have not been well described. In fact, there are very limited published data regarding the psychiatric services required by nursing home residents in general. One report indicated that 28%; of a public nursing home resident sample had received inpatient and/or outpatient psychiatric care prior to admission, and that 60% had received some contact after admission.9

In another report, patients with schizophrenia were found to account for a moderate proportion of the post-admission psychiatric contacts.18 The authors noted that 16% of 197 consecutive referrals over a 2-year period at six public and private nursing homes were due to patients with diagnoses of schizophrenia or paranoid disorder. The majority of consultations for these patients were due to either behavioral problems or psychotic symptoms. A statistically significant negative correlation was found between affective symptoms and diagnoses of schizophrenia or paranoid disorder, leading the authors to suggest that affective complications of such psychotic disorders were uncommon in nursing homes.

These data are similar to unpublished data from Monroe County Hospital, a public long-term care facility described previously.9 During 1994, 28 patients with schizophrenia were seen for a total of 102 visits (8% of all consultation visits). Visits per patient ranged from 1 to 26. Based on the use of a checklist administrative form developed to characterize the activity of the psychiatric consultation service, Table 4 describes the most frequent behavioral symptoms or problems noted at the time of consultation (each patient could have multiple problems). These data indicate that the problems identified most commonly were cognitive deficits, disruptive behavior, and anxiety. Table 5 describes the interventions or recommendations required by the same group of patients.

Table

TABLE 4Frequency of Problems Encountered in Consultation (28 patients, 102 total visits)

TABLE 4

Frequency of Problems Encountered in Consultation (28 patients, 102 total visits)

Table

TABLE 5Interventions and Recommendations (28 patients, 102 total visits)

TABLE 5

Interventions and Recommendations (28 patients, 102 total visits)

Table

TABLE 6Atypical Antipsychotic Medications Currently Under Development

TABLE 6

Atypical Antipsychotic Medications Currently Under Development

These findings may not be generalizable to other nursing homes because Monroe Community Hospital has a close working relationship with an academic medical center and a full-time consultation service. Most nursing homes are known to have extremely limited psychiatric services on site (C.A. Podgorski et al, unpublished data, 1990). The consultation service at Monroe Community Hospital allows complex problems to be managed there, with only the most severe problems requiring an admission to acute inpatient psychiatric services. This experience suggests that the presence of active psychiatric consultation in the nursing home may provide an alternative to hospitalization for many patients with schizophrenia. In addition, it suggests that patients with schizophrenia can be expected to use a significant proportion of psychiatric consultation services when such services are made available. An example of how psychiatric services can be made available to nursing homes on a large scale is Project ADAPT Currently in operation in Missouri, Texas, and Illinois, this program is sponsored by the state departments of mental health and provides comprehensive psychiatric care to deinstitutionalized elderly patients with severe mental illness.

CLINICAL PRESENTATION

Schizophrenia is known to be a heterogeneous disorder. Allowing for the limitations inherent in any generalization about this illness, the following section describes the "typical" presentation of patients with schizophrenia in nursing home settings. Such patients often present with scant prior medical and psychiatric histories, despite having had extensive stays in state psychiatric hospitals. Existing records may reflect clinical impressions and observations carried over from one annual note to another. Involvement of family and friends tends to be limited or absent. Financial resources or possessions are few. Although patients with schizophrenia are often in reasonably good physical health, they may present as underweight, with poor hygiene and ill-fitting clothes. Many patients are preoccupied with obtaining cigarettes, coffee, and soda. The level of physical activity varies significantly from patient to patient. While some patients with schizophrenia are very active and may pace the hallways, others are very inactive and may sit motionless for hours unless directed into an activity. Odd mannerisms and posture are frequent, as are muttering and other forms of disorganized speech.

Patients with schizophrenia are usually not disruptive, but may become angry, frightened, or irritable with unexpected verbal or physical contact or with environmental changes. While some patients will develop a worsening of psychotic symptoms during times of stress, the presentation of most patients is generally characterized by a preponderance of negative symptoms. Common negative symptoms include poverty of speech, lack of motivation, and lack of social involvement. Friendships are relatively rare among patients with schizophrenia and many will hover around the periphery of group activities without directly joining them. Strategies for managing patients with schizophrenia in nursing home settings are discussed in the following sections.

PHARMACOLOGIC MANAGEMENT

Antipsychotic medications have probably been overused in nursing homes,19 resulting in restriction of their use by the 1987 Omnibus Budget Reconciliation Act (OBRA). Despite such restrictions, antipsychotic medications remain the mainstay of treatment for patients with schizophrenia in late life. Review of the existing literature suggests that antipsychotic medications have a similar degree of effectiveness in young and elderly patients with schizophrenia.15'20 Most elderly patients require significantly lower doses, however, due to agerelated alterations in the pharmacology of antipsychotic medications. Aging is known to increase the sensitivity of individuals to antipsychotic medications through several mechanisms, including decreased protein binding (resulting in increased unbound drug), decreased hepatic metabolism (resulting in prolonged drug half-life), and central alterations in dopamine and acetylcholine neurotransmission.21 As a result of these changes, patients presenting with schizophrenia in late life are especially sensitive to the side effects of antipsychotic medications.

Up to 75% of all elderly patients who receive ongoing treatment with antipsychotic drugs will experience Parkinson's syndrome with tremor, rigidity, bradykinesia, and loss of postural reflexes.22 Management of neuroleptic-induced Parkinson's syndrome in elderly patients with schizophrenia consists initially of dosage reduction, with the goal of achieving the lowest effective dosage. This strategy may be followed, if necessary, by use of low doses of an anticholinergic drug such as benztropine (Cogentin). Due to an increased risk of anticholinergic side effects, anticholinergic medications should generally not be given prophylactically to elderly patients with schizophrenia. A trial of amantadme may be considered as an alternative treatment for patients who develop anticholinergic toxicity.21 While lowpotency antipsychotic medications may also be considered in patients who experience Parkinsonian side effects, the antiadrenergic and anticholinergic properties of these medications may limit their use.

Patients with schizophrenia in late life are also at increased risk for developing tardive dyskinesia resulting from antipsychotic drug use. In addition to advanced age, risk factors include a long duration of neuroleptic exposure, female gender, a history of acute extrapyramidal side effects, and the presence of an organic brain disorder or medical illness.21 Tardive dyskinesia in late life is characterized by choreoathetoid movements of the orofacial region, which may include lip smacking and sucking, lateral jaw movements and chewing, and tongue thrusting.23 Dyskinetic movements may also involve the extremities, but such involvement is less common in elderly patients compared to younger patients.24 Tardive dyskinesia in elderly patients is more common, severe, and persistent than in younger patients. It is present in over 40% of elderly inpatients with histories of prolonged neuroleptic treatment and persists in over half of such patients following neuroleptic withdrawal.25 Tardive dyskinesia is often first noticed in late life following drug withdrawal and will affect nearly 40% of initially asymptomatic patients.23

Management of tardive dyskinesia in nursing home settings includes tapering of neuroleptics to the minimum effective dosage, withdrawal of all anticholinergic medications, and discontinuation of stimulants including diet pills, allergy medications, and cough and cold medications.21 A number of medications have been used to treat tardive dyskinesia, but none have been consistently effective. Because of the potential irreversibility of tardive dyskinesia, information about tardive dyskinesia should be discussed with patients and their families, and all patients receiving neuroleptics should be carefully examined on a regular basis.

In addition to having increased susceptibility for extrapyramidal side effects, patients with schizophrenia in late life are particularly vulnerable to the antiadrenergic and anticholinergic properties of antipsychotic drugs. Orthostatic hypotension is a common antiadrenergic side effect and can result in serious injuries from falls. Common anticholinergic side effects include blurred vision, urinary hesitancy, constipation, and delirium. Antiadrenergic and anticholinergic side effects may be minimized through the use of high-potency antipsychotic drugs, although this potential advantage of high-potency drugs may be offset by their propensity to cause extrapyramidal side effects.

Clinicians treating nursing home patients with schizophrenia must weigh the relative advantages and disadvantages of low- and high-potency drugs based on their side effect profiles. Final selection of an antipsychotic drug is based on the drug's side effect profile, the patient's history of previous response, and the potential adverse interactions between the drug and preexisting medications or concomitant medical illnesses.20 Patients should receive a thorough medical and psychiatric evaluation prior to initiation of antipsychotic drug therapy. Antipsychotic drugs should be initiated at doses one fifth to one quarter of those used with younger patients.21 It is helpful to begin antipsychotic medications in divided daily doses in order to minimize the potential for hypotension and sedation. Because the appearance of both therapeutic effects and toxicity is often delayed in older patients, extra time should be allowed to lapse before making dosage increases.26 Intramuscular injection of antipsychotic drugs should generally be avoided due to pain and unpredictability of absorption that can occur in elderly patients because of their decreased muscle mass.'21

The role of atypical antipsychotic drugs in the treatment of nursing home patients with schizophrenia has not been determined, although these medications hold great promise for such patients. One potentially major advantage of atypical drugs compared to standard antipsychotic drugs is their relative lack of extrapyramidal side effects, including tardive dyskinesia.27"29 Of existing atypical agents, however, clozapine has strong sedative and anticholinergic properties, while risperidone and clozapine are both associated with significant orthostatic hypotension. Further research is needed to determine the tolerability and effectiveness of these medications and of new atypical agents in the treatment of this population. Table 6 lists promising new atypical antipsychotic drugs that are currently under development.

Given the increased susceptibility of elderly patients with schizophrenia to antipsychotic drug side effects, there have been surprisingly few studies of antipsychotic drug withdrawal in this population. Combining the results of all available studies, Jeste et al20 noted that following a mean of 6.3 (SD 3.0) months off neuroleptics, 39.9% (SD 12.0} of the patients relapsed compared to 11.4% (SD 11.8) of the patients who remained medicated (P<0.0001, matched-pair t test). These results suggest that long-term neuroleptic discontinuation may be feasible for only a minority of patients with schizophrenia in late life.

A number of medications are available as adjuncts to antipsychotic medications in the treatment of patients with schizophrenia, including lithium, anticonvulsants, beta blockers, and benzodiazepines. Because use of multiple medications significantly increases the risk of adverse reactions in elderly patients, however, such use should generally be minimized. ECT may be considered as an alternative to antipsychotic drugs for those patients who are unable to tolerate them, especially if affective or catatonic features are present.26 Patients who present with catatonia may also respond to a trial of benzodiazepine alone.30

PSYCHOSOCIAL MANAGEMENT

To our knowledge, there are no published controlled clinical trials of any psychosocial intervention for patients with schizophrenia in nursing homes. While a variety of approaches have been shown to be effective in managing depression and medical illness in long-term care settings,31 the effectiveness of these approaches has not been studied among patients with schizophrenia. Despite this lack of empirical data, the following practical guidelines may be helpful in conducting psychosocial interventions with this population.

Optimal psychosocial management of patients with schizophrenia in the nursing home should begin with basic education of nursing home staff Most direct care in nursing homes is provided by nursing aides who receive little instruction in the identification or management of schizophrenia. Unfortunately, a similar lack of knowledge often exists among professional staff as well. Education should include demystifying schizophrenia because many staff members will have inaccurate expectations, for example, that patients with schizophrenia are violent or have split personalities. It is helpful to explain the major clinical features of schizophrenia, including positive symptoms, for which properly used medications are often effective, and negative symptoms, which require consistent and sensible psychosocial management. It is also helpful to note that patients with schizophrenia are vulnerable to stress, and that worsening of psychotic symptoms may occur in response to stressful life events. Such explanation can provide a solid groundwork for development of care plans that address the comprehensive needs of this population.

Psychosocial management of schizophrenia in the nursing home requires the establishment of supportive relationships between patients and staff In developing a supportive relationship, staff members should balance their active attempts to engage a patient with the provision of physical and psychological "space" if a patient becomes overstimulated. Staff should also assist patients in learning the basic rules and physical layout of the nursing home. Adjustment of patients with schizophrenia to the nursing home environment can be promoted through use of signs, proper lighting, and repetition, in addition to the use of encouragement.

Given the social isolation experienced by many patients with schizophrenia, efforts should be made to provide stimulation and to increase social supports. A variety of group approaches may be helpful, including cognitive-behavioral, reminiscence, exercise, and socialization groups. Despite the potential benefits of group therapy, however, it is often unused in nursing homes. Patients with schizophrenia can also enjoy and benefit from physical or other recreational activities. In addition, family members should be encouraged to maintain contact if they are available. The continued involvement of families can be supported through family meetings at least twice a year. It is also helpful to determine whether patients are able to engage in tasks or jobs that provide tokens or money as reinforcement. Such jobs may need to be fairly routinized and involve limited contact with others, such as mail delivery, dining room clean-up, laundry work, or gardening. However simple, these jobs can substantially improve social skills and selfesteem. In general, the attainment of lasting benefits from psychosocial interventions requires that the interventions are provided in an ongoing rather than a time-limited manner.

CONCLUSION

A significant number of patients in nursing homes carry the diagnosis of schizophrenia. These patients may live for many years after placement and are typically cared for by personnel with little or no training in the diagnosis or management of mental disorders. When psychiatric services are available, these patients appear to require moderate but significant amounts of psychiatric input. Unfortunately, despite being de facto psychiatric facilities, most nursing homes lack the personnel, programs, or training to address the legitimate mental health needs of these patients.

In order to provide better care, the nursing home industry and psychiatry need to work together to clarify the management needs of patients with schizophrenia. These include improved access to routine psychiatric services, improved social and recreational opportunities, and systematic training of administrators, primary care physicians, nurses, and aides. The last group is particularly important, as they provide more than 90% of the hands-on care to nursing home patients.

REFERENCES

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5. Wing JK. Long-term social adaptation in schizophrenia. In: Miller NE, Cohen GD. Schizophrenia and Aging. New York, NY: Guilford Press; 1987:183-188.

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15. Pearlson G, Rabins P. The late-onset psychoses; possible risk factors. Psychiatr Clin North Am. 1988; 11:15-32.

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17. Yassa R, Suranyi-C adotte B. Clinical characteristics of late-onset schizophrenia and delusional disorder. SchizophrBuli. 1993; 19:701-707.

18. Loebel JP, Borson S, Hyde T, et al. Relationships between requests for psychiatric consultations and psychiatric diagnoses in long-term-care facilities. Am J Psychiatry. 1991; 148:898-903.

19. Rovner BW, German PS, Broadhead J, et al. The prevalence and management of dementia and other psychiatric disorders in nursing homes. Int Psychogeriatr. 1990; 2: 13-24.

20. Jeste DV, Lacro JP, Gilbert PL, Kline J, Kline N. Treatment of late-life schizophrenia with neuroleptics. Schizophr Bull. 1993; 19:817-830.

21. Lohr JB, Jeste DV, Harris MJ, Salzman C. Treatment of disordered behavior. In: Salzman C, ed. Clinical Geriatric Psychopharmacology. Baltimore, MD: Williams & Wilkins; 1992:79-113.

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TABLE 1

Long-Term Outcome Studies of Schizophrenia (Stable End-States Over 5 Years)

TABLE 2

Summary of Modern Prevalence Studies

TABLE 3

Common Causes of Psychotic Symptoms in the Elderly

TABLE 4

Frequency of Problems Encountered in Consultation (28 patients, 102 total visits)

TABLE 5

Interventions and Recommendations (28 patients, 102 total visits)

TABLE 6

Atypical Antipsychotic Medications Currently Under Development

10.3928/0048-5713-19950701-14

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