Personalizing Antipsychotic Treatment of Schizophrenia

Despite the availability of efficacious antipsychotic drugs, the pharmacological management of schizophrenia remains a challenge, and it largely follows a trial-and-error paradigm. With notoriously high rates of poor antipsychotic drug adherence and limited means to detect it, prescribers are often uncertain whether a lack of treatment response is due to poor adherence or true lack of effect. Moreover, when encountering a patient with intolerable side effects, prescribers do not know whether to switch to another drug or merely reduce the dose. This uncertainty results in unnecessarily high rates of unwarranted treatment changes and antipsychotic polypharmacy, loss of adherence and disease control, and ultimately poor patient and societal outcomes. In this Perspective, we argue that point-of-care information on antipsychotic plasma levels — the amount of drug circulating in the patient's blood — will result in better patient care, which should lead to better health and better value for the health care system. While tests for antipsychotic plasma levels have long been available through specialized labs, they are not routinely used, in part because of delays in obtaining results. Access to information on antipsychotic plasma levels at the point of care would facilitate better use of currently available drugs and reduce the uncertainty associated with the management of complicated presentations by providing prescribers with a tool to "personalize" treatment to patients' characteristics, including responsiveness to specific medications, metabolism, and adherence behavior.