The American Psychiatric Association has released a new evidence-based practice guideline for the treatment of schizophrenia.
Dr. George Keepers
The guideline focuses on assessment and treatment planning, which are integral to patient-centered care, and includes recommendations regarding pharmacotherapy, with particular focus on clozapine, as well as previously recommended and new psychosocial interventions.
“Our intention was to make recommendations to treat the whole person and take into account their family and other significant people in their lives,” George Keepers, MD, chair of the guideline writing group, said in an interview.
‘State-of-the-art methodology’
Dr. Keepers, professor of psychiatry at Oregon Health and Science University, Portland, explained the rigorous process that informs the current guideline, which was “based not solely on expert consensus but was preceded by an evidence-based review of the literature that was then discussed, digested, and distilled into specific recommendations.”
Many current recommendations are “similar to previous recommendations, but there are a few important differences,” he said.
Two experts in schizophrenia who were not involved in guideline authorship praised it for its usefulness and methodology.
Philip D. Harvey, PhD, Leonard M. Miller Professor of Psychiatry and Behavioral Sciences, University of Miami, said in an interview that the guideline “clarified the typical treatment algorithm from first episode to treatment resistance [which is] very clearly laid out for the first time.”
Christoph Correll, MD, professor of psychiatry and molecular medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, N.Y., said in an interview that the guideline “followed state-of-the-art methodology.”
First steps
The guideline recommends beginning with assessment of the patient and determination of the treatment plan.
Patients should be “treated with an antipsychotic medication and monitored for effectiveness and side effects.” Even after the patient’s symptoms have improved, antipsychotic treatment should continue.
For patients whose symptoms have improved, treatment should continue with the same antipsychotic and should not be switched.
“The problem we’re addressing in this recommendation is that patients are often treated with an effective medication and then forced, by circumstances or their insurance company, to switch to another that may not be effective for them, resulting in unnecessary relapses of the illness,” said Dr. Keepers.
“ and do what’s in the best interest of the patient,” he said.
“The guideline called out that antipsychotics that are effective and tolerated should be continued, without specifying a duration of treatment, thereby indicating indirectly that there is no clear end of the recommendation for ongoing maintenance treatment in individuals with schizophrenia,” said Dr. Correll.
Clozapine underutilized
The guideline highlights the role of clozapine and recommends its use for patients with treatment-resistant schizophrenia and those at risk for suicide. Clozapine is also recommended for patients at “substantial” risk for aggressive behavior, regardless of other treatments.
“Clozapine is underutilized for treatment of schizophrenia in the U.S. and a number of other countries, but it is a really important treatment for patients who don’t respond to other antipsychotic agents,” said Dr. Keepers.
“With this recommendation, we hope that more patients will wind up receiving the medication and benefiting from it,” he added.
In addition, patients should receive treatment with a long-acting injectable antipsychotic “if they prefer such treatment or if they have a history of poor or uncertain adherence” (level of evidence, 2B).
The guideline authors “are recommending long-acting injectable medications for people who want them, not just people with poor prior adherence, which is a critical step,” said Dr. Harvey, director of the division of psychology at the University of Miami.