Practice Guideline for the Treatment of Partients with Schizophrenia, Second Edition

A. Coding System: Each recommendation is identified as falling into one of three categories of endorsement, indicated by a bracketed Roman numeral following the statement. The three categories represent varying levels of clinical confidence regarding the recommendation: [I] Recommended with substantial clinical confidence [II] Recommended with moderate clinical confidence [III] May be recommended on the basis of individual circumstances. B. Formulation and Implementation of a Treatment Plan: Because schizophrenia is a chronic illness that influences virtually all aspects of life of affected persons, treatment planning has three goals: 1) reduce or eliminate symptoms, 2) maximize quality of life and adaptive functioning, and 3) promote and maintain recovery from the debilitating effects of illness to the maximum extent possible. Accurate diagnosis has enormous implications for short- and long-term treatment planning, and it is essential to note that diagnosis is a process rather than a one-time event. As new information becomes available about the patient and his or her symptoms, the patient's diagnosis should be reevaluated, and, if necessary, the treatment plan changed. Once a diagnosis has been established, it is critical to identify the targets of each treatment, to have outcome measures that gauge the effect of treatment, and to have realistic expectations about the degrees of improvement that constitute successful treatment [I]. Targets of treatment, and hence of assessment, may include positive and negative symptoms, depression, suicidal ideation and behaviors, substance use disorders, medical comorbidities, posttraumatic stress disorder (PTSD), and a range of potential community adjustment problems, including homelessness, social isolation, unemployment, victimization, and involvement in the criminal justice system [I]. After the initial assessment of the patient's diagnosis and clinical and psychosocial circumstances, a treatment plan must be formulated and implemented. This formulation involves the selection of the treatment modalities, the specific type(s) of treatment, and the treatment setting. Periodic reevaluation of the diagnosis and the treatment plan is essential to good clinical practice and should be iterative and evolve over the course of the patient's association with the clinician [I]. C. Establishing a Therapeutic Alliance: A supportive therapeutic alliance allows the psychiatrist to gain essential information about the patient and allows the patient to develop trust in the psychiatrist and a desire to cooperate with treatment. Identifying the patient's goals and aspirations and relating these to treatment outcomes fosters the therapeutic relationship as well as treatment adherence [II]. The clinician may also identify practical barriers to the patient's ability to participate in treatment, such as cognitive impairments or disorganization and inadequate social resources. Engagement of the family and other significant support persons, with the patient's permission, is recommended to further strengthen the therapeutic effort [I]. The social circumstances of the patient can have profound effects on adherence and response to treatment. Living situation, family involvement, sources and amount of income, legal status, and relationships with significant others (including children) are all areas that may be periodically explored by mental health care clinicians [II]. The psychiatrist can work with team members, the patient, and the family to ensure that such services are coordinated and that referrals for additional services are made when appropriate. The family's needs can be addressed and an alliance with family members can be facilitated by providing families with information about community resources and about patient and family organizations such as the National Alliance for the Mentally Ill (NAMI) [II]. Many patients with schizophrenia require, and should receive, a variety of treatments, often from multiple clinicians. It is therefore incumbent on clinicians to coordinate their work and prioritize their efforts. Because an accurate history of past and current treatments and responses to them is a key ingredient to treatment planning, excellent documentation is paramount [I]. Especially critical, for example, is information about prior treatment efforts and clinical response. D. Acute Phase Treatment: The goals of treatment during the acute phase of treatment, defined by an acute psychotic episode, are to prevent harm, control disturbed behavior, reduce the severity of psychosis and associated symptoms (e.g., agitation, aggression, negative symptoms, affective symptoms), determine and address the factors that led to the occurrence of the acute episode, effect a rapid return to the best level of functioning, develop an alliance with the patient and family, formulate short- and long-term treatment plans, and connect the patient with appropriate aftercare in the community. Efforts to engage and collaborate with family members and other natural caregivers are often successful during the crisis of an acute psychotic episode, whether it is the first episode or a relapse, and are strongly recommended [1]. Family members are often under significant stress during this time. Also, family members and other caregivers are often needed to provide support to the patient while he or she is recovering from an acute episode. It is recommended that every patient have as thorough an initial evaluation as his or her clinical status allows, including complete psychiatric and general medical histories and physical and mental status examinations [I]. Interviews of family members or other persons knowledgeable about the patient may be conducted routinely, unless the patient refuses to grant permission, especially since many patients are unable to provide a reliable history at the first interview [I]. The most common contributors to symptom relapse are antipsychotic medication non-adherence, substance use, and stressful life events, although relapses are not uncommon as a result of the natural course of the illness despite continuing treatment. If nonadherence is suspected, it is recommended that the reasons for it be evaluated and considered in the treatment plan. General medical health as well as medical conditions that could contribute to symptom exacerbation can be evaluated by medical history, physical and neurological examination, and appropriate laboratory, electrophysiological, and radiological assessments [I]. Measurement of body weight and vital signs (heart rate, blood pressure, temperature) is also recommended [II]. Other laboratory tests to be considered to evaluate health status include a CBC; measurements of blood electrolytes, glucose, cholesterol, and triglycerides; tests of liver, renal, and thyroid function; a syphilis test; and when indicated and permissible, determination of HIV status and a test for hepatitis C [II]. Routine evaluation of substance use with a toxicology screen is also recommended as part of the medical evaluation [I]. A pregnancy test should be strongly considered for women with childbearing potential [II]. In patients for whom the clinical picture is unclear or where there are abnormal findings from a routine examination, more detailed studies (e.g., screening for heavy metal toxins, EEG, magnetic resonance imaging [MRI] scan, or computed tomography [CT] scan) may be indicated [II]. It is important to pay special attention to the presence of suicidal potential and the presence of command hallucinations and take precautions whenever there is any question about a patient's suicidal intent, since prior suicide attempts, current depressed mood, and suicidal ideation can be predictive of a subsequent suicide attempt in schizophrenia [I]. Similar evaluations are recommended in considering the likelihood of dangerous or aggressive behavior and whether the person will harm someone else or engage in other forms of violence [I]. It is recommended that pharmacological treatment be initiated promptly, provided it will not interfere with diagnostic assessment, because acute psychotic exacerbations are associated with emotional distress, disruption to the patient's life, and a substantial risk of dangerous behaviors to self, others, or property [I]. Before the patient begins treatment with antipsychotic medication, it is suggested that the treating physician, as is feasible, discuss the potential risks and benefits of the medication with the patient [I].