New Schizophrenia Treatment Guideline Released

Batya Swift Yasgur, MA, LSW

September 03, 2020

The American Psychiatric Association (APA) has released a new evidence-based practice guideline for the treatment of schizophrenia.

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, told Medscape Medical News.

"State-of-the-Art Methodology"

Keepers, who is professor of psychiatry at Oregon Health and Science University, Portland, Oregon, 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 Miller School of Medicine, Miami, Florida, told Medscape Medical News 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, New York, told Medscape Medical News 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.

Recommendation Components Level of evidence
Initial assessment
  • Reason patient is presenting

  • Patient's goals/preferences for treatment

  • Psychiatric symptoms

  • Trauma history

  • Tobacco/substance use

  • Psychiatric treatment history

  • Physical health

  • Mental status/cognitive assessment

  • Suicidality

  • Aggressive behaviors

1C
Psychiatric evaluation
  • Quantitative measure to determine symptom severity/functional impairment

1C
Documented, comprehensive, person-centered treatment plan
  • Pharmacotherapy

  • Psychotherapy

1C

 

Continue Antipsychotics

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 Keepers.

"All we can do is recommend appropriate treatment and hope that the decision makers of the insurance companies will heed these recommendations 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 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 US and a number of other countries, but it is a really important treatment for patients who don't respond to other antipsychotic agents," said Keepers.

"With this recommendation, we hope that more patients will wind up receiving the medication and benefiting from it," he added.

Additionally, 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," commented Harvey, who is the director of the Division of Psychology at the University of Miami.

Managing Antipsychotic Side Effects

The guideline offers recommendations for patients experiencing antipsychotic-induced side effects.

Side effect Treatment options Level of evidence
Acute dystonia
  • Anticholinergic medication

1C
Parkinsonism
  • Lower antipsychotic dosage

  • Switch to another antipsychotic

  • Anticholinergic medication

2C
Akathisia
  • Lower antipsychotic dosage

  • Switch to another antipsychotic

  • Add benzodiazepine

  • Add β-adrenergic blocker

2C
Moderate to severe tardive dyskinesia
  • Reversible inhibitor of the vesicular monoamine-transporter-2 (VMAT2)

1B

 

VMAT2s, which represent a "class of drugs that have become available since the last schizophrenia guidelines, are effective in tardive dyskinesia. It is important that patients with tardive dyskinesia have access to these drugs because they do work," Keepers commented.

Adequate Funding Needed

Recommended psychosocial interventions include treatment in a specialty care program for patients with schizophrenia who are experiencing a first episode of psychosis; use of cognitive-behavioral therapy for psychosis; psychoeducation; and supported employment services (2B).

"We reviewed very good data showing that patients who receive these services are more likely to be able to be employed and less likely to be rehospitalized or have a relapse," Keepers observed.

Additionally, patients with schizophrenia should receive assertive community treatment interventions if there is a "history of poor engagement with services leading to frequent relapse or social disruption" (2B).

Family interventions are recommended for patients who have ongoing contact with their family (2B), and patients should also receive interventions "aimed at developing self-management skills and enhancing person-oriented recovery." They should also receive cognitive remediation, social skills training, and supportive psychotherapy (2C).

Keepers pointed to "major barriers" to providing some of these psychosocial treatments. "They are beyond the scope of someone in an individual private practice situation, so they need to be delivered within the context of treatment programs that are either publicly or privately based," he said.

"Psychiatrists can and do work closely with community and mental health centers, psychologists, and social workers who can provide these kinds of treatments," but "many [treatments] require specialized skills and training before they can be offered, and there is a shortage of personnel to deliver them," he noted.

"Both the national and state governments have not provided adequate funding for treatment of individuals with this condition [schizophrenia]," he added.

Keepers reports no relevant financial relationships. The other authors' disclosures are listed on the original article. Harvey reports no relevant financial relationships. Correll reports having been a consultant and/or advisor to or having received honoraria from Acadia, Alkermes, Allergan, Angelini, Axsome, Gedeon Richter, Gerson Lehrman Group, Indivior, IntraCellular Therapies, Janssen/J&J, LB Pharma, Lundbeck, MedAvante-ProPhase, Medscape, Merck, Mylan, Neurocrine, Noven, Otsuka, Pfizer, Recordati, Rovi, Servier, Sumitomo Dainippon, Sunovion, Supernus, Takeda, and Teva. He has received grant support from Janssen and Takeda. He is also a stock option holder of LB Pharma.

Am J Psychiatry. Published online September 1, 2020. Executive summary, Full text; Guideline, Full text

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