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In this episode, we welcome Brooke Kempf, a psychiatric mental health nurse practitioner, to debunk common myths about schizophrenia and promote a more accurate understanding of the condition. We’ll explore misconceptions about the causes and effects of schizophrenia, the impact of socioeconomic status, and the role of genetic and environmental factors. Brooke will share insights on the importance of early and consistent treatment, the benefits of long-acting injectables, and the critical role of psychosocial support.

Brooke Kempf is a psychiatric mental health nurse practitioner.

She discusses the KevinMD article, “Debunking the top myths about schizophrenia.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Brooke Kempf. She’s a psychiatric mental health nurse practitioner. Today’s KevinMD article is “Debunking the top myths about schizophrenia.” Brooke, welcome to the show.

Brooke Kempf: Thank you, thank you very much for having me.

Kevin Pho: So let’s start by briefly sharing your story and journey.

Brooke Kempf: OK, so I’m based out of Terre Haute, Indiana. I’m a psychiatric mental health nurse practitioner. I started my psych career straight out of nursing school. So in nursing school I identified right away that psych was my area, that I wanted to be absolutely, became passionate about it. And I actually grew up just three blocks down the road from our community mental health center. I applied with them right out of nursing school, got placed on an inpatient unit right away, and that is literally where I was for the last 29 years, at that same community mental health center.

Worked inpatient, outpatient. While I was outpatient, they didn’t really know what to do with me. We had long acting injectables then, back then we just had Haldol Decanoate, Prolixin Decanoate. But we knew that patients did not take their medications very well. None of us take our medications very well. But we identified a way to monitor patients’ meds, that grew into a large program.

I spent most of my outpatient nursing career as the group home nurse, which was probably my favorite career, because I got to spend day in, day out with patients with chronic mental illness, and really got to learn these individuals as people, not their diagnosis.

Luckily Hamilton Center identified that there is a severe shortage of psychiatrists, not just in our area but nationwide, and they knew that we were going to need advanced practice nurses at that time. So in 2008 they requested I go back to school. I didn’t want to, loved what I did, but with their support and encouragement I went back to school, became a psychiatric nurse practitioner in 2010, did outpatient.

My most recent position was the hospitalist for our inpatient unit. And I also started teaching for IUPUI and their psychiatric nurse practitioner program, and some pharmaceutical companies, providing education. And I actually just finished up, kind of semi-retired from our community mental health career after 29 years, just March of this year, but continue to do education.

Kevin Pho: All right. So obviously a long career in the field of psychiatry. In general, tell us some of the rewards and challenges in the field of psychiatry today.

Brooke Kempf: Yeah, I would love to say those balance equally, but they don’t always. I really, really strongly believe the stigma against mental illness is a huge barrier, as clinicians getting treatment to patients, but most of all our patients being discriminated against, our patients not wanting to reach out for help because of that stigma.

So there’s this huge disconnect between the treatment options that are becoming available and getting those patients treatment. So that’s a huge challenge. And then our treatments that we have had, we’ve used the same treatments for several decades now, and so we are finally coming about getting new treatment options. But again, we have to get rid of the stigma in order for patients to feel comfortable to come forward and ask for help.

Kevin Pho: All right. So let’s talk about your KevinMD article. We’re going to focus on schizophrenia. Your KevinMD article is titled “Debunking the top myths about schizophrenia.” So for those who didn’t get a chance to read your article, tell us what it’s about.

Brooke Kempf: Sure. So in talking about educating our peers, our peers are getting educated about schizophrenia in general, but we really identified that the general population still has these misconceptions on what schizophrenia is. They believe that patients with schizophrenia are dangerous by some means. They don’t understand that this is an actual, just, medical diagnosis.

I feel that we picture patients with schizophrenia as sick all the time, and these are individuals with a medical diagnosis just like something like diabetes, hypertension. If you had diabetes and you had an episode of hyperglycemia and your blood sugar’s 400, you go through an episode, you get treatment, but the majority of the time you’re well.

The same thing with patients with schizophrenia. They might have a psychotic episode in which they experience symptoms of psychosis, or maybe the negative symptoms impact some of their day-to-day functioning, but the majority of time with treatment these patients are well. They function independently in society, they are not dangerous.

Yes, absolutely there are some circumstances in which a patient might have an episode in which they, you know, become argumentative with somebody due to their psychosis. But again, the majority of these times these are highly functional individuals, intelligent by nature, and we need to learn to treat them just like individuals, not like an illness.

Kevin Pho: Now, just to get everyone on the same page, give us a 30-second definition of what schizophrenia is.

Brooke Kempf: Absolutely. So a definition of schizophrenia is an individual that has psychosis, so psychotic symptoms. What we call positive symptoms would be things like hallucinations, hearing things, seeing things, smelling things, feeling things. But then also negative symptoms, those things we’re not as familiar with sometimes. So those negative symptoms are like amotivation, where an individual, basically those things that we, the communication that we see normally amongst people, you may not see them being as interactive with others, a little bit more withdrawn. Those are negative symptoms.

But then there’s also cognitive impairment that is associated with the illness, so sometimes their functioning level seems to be deteriorating. All of this though, the more episodes that the patient has with schizophrenia, the permanent damage is happening. So what we really want to promote is early intervention. Those individuals that are early diagnosed and receive treatment, we can prevent that damage from happening. So the severity of those symptoms that I just mentioned do not have to reach a certain level, we can maintain them at a very good baseline.

Kevin Pho: So what would be some common presentations of schizophrenia? I’m a primary care physician, so let’s say if I’m meeting a patient for the first time in my exam room, what are some of the things that I should look out for? What are some pieces from that patient’s story that would lead me to think that, hey, potentially I need to be thinking schizophrenia?

Brooke Kempf: Getting a very clear history, looking at family history. There is a genetic component that we know. There’s no specific cause of schizophrenia, we’re still trying to figure that out, it’s generally a multitude of things that happen between genetics and environment. But getting a clear family history, is there any mental health history within the family?

Asking somebody if they are paranoid or delusional, that’s not going to come across very well. So picking up on little hints, such as, a patient might come to a primary care provider complaining of multiple somatic complaints. They believe they have something in their stomach, they believe that somebody is out to get them. You’re asking them questions and they seem kind of hesitant to answer questions, become suspicious of you.

Often you probably are going to need, if possible, to get outside influence in there. So is there a family member that can attend an appointment? That’s where we often get initial contact, a family member contacts us and lets us know, hey, my loved one is behaving abnormally, they’re up at night, they are checking windows, they are talking to somebody in the room that is not there, they are withdrawn.

And if we catch these symptoms very early, when we look at the prodromal stages, what we see in early adolescence are those individuals that you start noticing a decline in their normal functioning. So they become more withdrawn, they’re not as social, they’re not communicating as well. So if you start picking up on your patient that does seem to be having difficulty communicating with you, again, just diving deeper into that initial history and exam.

Kevin Pho: You said earlier that with schizophrenia specifically there are a lot of misperceptions and misconceptions about that condition. Why do you think there are so many misperceptions specifically with schizophrenia?

Brooke Kempf: Unfortunately I think the general population gets a lot of their information from social media, media in general. If you look, unfortunately, at the news, a lot of times any type of criminal behavior, they immediately make reference to an individual’s mental health suffering. There might even be movies that depict an individual with schizophrenia as extremely bizarre and crazy and evil. And if that’s the only thing an individual knows about schizophrenia, they have the misperception that that’s how schizophrenia actually is, and that’s how people with schizophrenia are all of the time. And so unfortunately it’s just lack of education.

Kevin Pho: So give us some counter examples. What would be some hypothetical case studies or patients that have schizophrenia that counter those stereotypes?

Brooke Kempf: Absolutely, and it’s the majority of patients with schizophrenia. So if you look at psychotic episodes, those periods of time in which a patient experiences an episode that might require them to go into the hospital because their symptoms are that severe, that generally happens maybe a couple times a year, and that’s generally untreated.

But if you have the treated individual that is on medications and managed very well, those individuals function just like you or I do. They can work, they drive, they can live independently, they don’t have to live in a structured environment, they aren’t sent off to state hospitals. Our primary goal is to treat patients with the least restrictive environment.

In my experience over 25 years working with patients, absolutely there are those that are on disability and do require extra assistance, case management, those things, to get to that level of functioning. But then there’s also a lot of those individuals graduate college, they have professional positions. I work with individuals that work in banks, I work with nurses that have schizophrenia, I work with a social worker that has schizophrenia. They can be highly intelligent, highly functional individuals that have no criminal history whatsoever. The majority of those individuals with schizophrenia have no criminal history.

Kevin Pho: So let’s say I have a patient I suspect that may have schizophrenia, and I send that patient to a behavioral health specialist like yourself. Tell us about some of the initial approaches, treatments that you would take with that patient. Currently we’re speaking in July 2024.

Brooke Kempf: Absolutely. I’m very excited, we have new emerging options coming. Most of our options have had to do with dopamine hypothesis of schizophrenia. Absolutely there’s a role of dopamine when it comes to the treatment of schizophrenia, most of our treatments have surrounded that. We have new ideas coming, great new treatment options coming.

I’m a strong advocate and believer in long-acting injectables. As I mentioned before, none of us are good at taking medication, and medication adherence is my primary goal for the treatment of schizophrenia. Early intervention is a very high need. If I can intervene early, get patients on a long-acting injectable, or ensure they’re on a medication that is tolerable and effective for them from the beginning, I can prevent all that long-term damage.

So my initial approach, I have to develop a good relationship. As we mentioned, these patients could have some paranoia. It’s been very hard for them to reach out and ask for assistance, they know the stigma, they have the misperceptions too. So I have to educate them on the illness, assure them it’s nothing that they did, nothing that anybody’s done to them that has caused this illness, provide them that education, and educate them on the treatment options available out there.

Again, I try to introduce long-acting injectables, because I don’t want these individuals to have to think day in, day out about their illness. If I can get an individual on an injection and they have to come in, or they take medication once a month, we have options now where they only have to take them once every two months. There’s even a long-acting injectable that treats schizophrenia that you only have to take twice a year.

If I can have an individual come in and I can let them know, hey, you may not even have to take a pill every single day, if we can find an effective option you may only have to take treatment once a month, this doesn’t have to be your life, that usually strikes their interest. And it seems less impactful. There’s so much now we can work on. Being sure that you stay in school, now we can be sure that you can develop these relationships with your girlfriend, you can get married, you can live a normal functioning life and not have to worry about, every day, I’m sick, I’m sick, I’m sick.

So it comes with developing a therapeutic relationship, educating, and then finding an appropriate treatment option for them.

Kevin Pho: Now, what would be some examples of some names of these long-acting injectables that you would prescribe? And is it something that patients inject themselves, do they have to come to an office? And maybe speak to their effectiveness.

Brooke Kempf: Absolutely. So all of these medications have been proven to decrease hospitalizations, and if you look at long-term data when it comes to long-acting injectables, they even have evidence of decreasing things like mortality.

So when it comes to what options do we have, we have Abilify Maintena, Abilify Asimtufii, Aristada, Aristada Initio, Invega Sustenna, Invega Trinza, Invega Hafyera, Uzedy, Perseris. So these all need to be administered by a health care professional, so generally given in an office. Pharmacies, there are some pharmacists that can administer these injections. They’re not self-administered. They’re IM injections, and then we have subQ injections also available.

Kevin Pho: What are some of the other misperceptions or myths of schizophrenia that you wrote in your article that you wanted to dispel here?

Brooke Kempf: That somehow these caused schizophrenia, or it was specifically their environment. That schizophrenia, it is again, it’s a multitude of different factors.

These individuals don’t have split personalities. You hear that often, even because patients might behave differently when they’re experiencing a psychotic episode, people, they have a split personality. And again it’s not like the movie that we see, the movie Split out there. There is a mental health diagnosis, dissociative identity disorder, that has to do with split personalities, very rare. When it comes to schizophrenia, these individuals may behave differently when they’re experiencing psychosis, but they don’t have a split personality.

Nothing that they caused by themselves. Again, they’re often subjects of violence rather than actually committing violence, unfortunately, and that’s because sometimes they’re in vulnerable situations.

Let’s see, was there anything else? Basically that it’s untreatable, that these patients are going to be sick for the rest of their lives. And first and foremost, that it is a medical diagnosis, no different than any other medical diagnosis that we have. It just happens to be a different organ. You know, when we treat hypertension we talk about the heart, when we talk about the pancreas and diabetes, we’re talking about schizophrenia, it is a medical diagnosis of the brain. That is the only difference. And really wanting to look at it as a medical diagnosis, rather than something so different, that mental health is different.

And I’m very, very thankful that we’re trying to reduce the stigma when it comes to mental health in general. However, there’s acceptance when we talk about, you know, you go on walks for suicide, you have these initiatives for depression, PTSD, veterans, all this is so, so important. But when was the last time that you heard somebody trying to do a benefit for patients with schizophrenia? It is still on the back burner, and it’s still to me one of those most highly stigmatized mental health diagnoses, just due to misunderstanding.

Kevin Pho: As you know, there’s a shortage of behavioral health specialists. Sometimes it’s very difficult to refer someone, or for someone to find a behavioral health specialist. What’s the role of a primary care physician like myself in managing someone with schizophrenia, when it’s so hard for them to see a psychiatrist or an advanced practice practitioner?

Brooke Kempf: Oh absolutely. And unfortunately we have stigma within our own medical community also. And if I ever hear another medical professional, sometimes they’ll say, oh well, I’m glad that you’re willing to do mental health because I don’t want to. Well, anybody in the medical field is going to have to provide some mental health services, because there is such a shortage.

And while you are waiting for that individual to get treatment, you’re going to have to do something. First and foremost, identify, is there a crisis? So if at any point in time your patient is in crisis, that would mean you really truly feel that patient’s in danger of harming themselves or harming someone else due to their current condition, you want to get them to an inpatient psychiatric hospital through an emergency room or through their inpatient facility as quickly as possible. That has to be addressed immediately.

But the day-to-day things, you just need to provide yourself education. Go to a conference, do continuing education when it comes to the treatment options for schizophrenia. You may have a patient that’s transferred from a different state and you need to see them for a while until they get into that mental health professional. You may need to continue their mental health medications. You have to be educated on those so that you feel comfortable in continuing those.

There’s nothing more frustrating than hearing that a medical provider wasn’t able to continue medications because they didn’t understand the medicines and weren’t willing to continue those medicines just for that period of time. Absolutely, it might be out of someone’s scope and they’re not willing to continue during that time period, but you might unfortunately have to.

Kevin Pho: We’re talking to Brooke Kempf. She’s a psychiatric mental health nurse practitioner. Today’s KevinMD article is “Debunking the top myths about schizophrenia.” Brooke, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Brooke Kempf: Absolutely. I think first and foremost we have to all work together in our community to decrease the stigma. Educate ourselves, educate others, reminding them that this is just a medical condition. The more that we destigmatize this, the more comfortable individuals are going to be able to ask for help, and that is the primary goal in treatment.

We’ve got to provide early intervention and provide effective treatments that patients are going to be able to tolerate and be effective, so that we can provide them the highest ability to function completely independently and function to the best of their ability.

Kevin Pho: Brooke, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Brooke Kempf: Thank you so much.