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.
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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].
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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.
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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 [I].
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 nonadherence,
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].
The selection of an antipsychotic medication is frequently guided
by the patient's previous experience with antipsychotics,
including the degree of symptom response, past experience of side
effects, and preferred route of medication administration. In choosing
among these medications, the psychiatrist may consider the patient's
past responses to treatment, the medication's side effect
profile (including subjective responses, such as a dysphoric response
to a medication), the patient's preferences for a particular
medication based on past experience, the intended route of administration,
the presence of comorbid medical conditions, and potential interactions
with other prescribed medications [I]. Finally,
while most patients prefer oral medication, patients with recurrent
relapses related to nonadherence are candidates for a long-acting
injectable antipsychotic medication, as are patients who prefer
this mode of administration [II].
The recommended dose is that which is both effective and not
likely to cause side effects that are subjectively difficult to
tolerate, since the experience of unpleasant side effects may affect
long-term adherence [I]. The dose may be titrated
as quickly as tolerated to the target therapeutic dose of the antipsychotic
medication, and unless there is evidence that the patient is having
uncomfortable side effects, monitoring of the patient's
clinical status for 2–4 weeks is warranted to evaluate
the patient's response to the treatment [II].
During these weeks it is often important for physicians to be patient and
avoid the temptation to prematurely escalate the dose for patients
who are responding slowly [I]. If the patient
is not improving, it may be helpful to establish whether the lack
of response can be explained by medication nonadherence, rapid medication
metabolism, or poor absorption [II].
Adjunctive medications are also commonly prescribed for comorbid
conditions in the acute phase. Benzodiazepines may be used to treat
catatonia as well as to manage both anxiety and agitation until the
antipsychotic has had time to be therapeutically effective [II].
Antidepressants can be considered for treating comorbid major depression
or obsessive-compulsive disorder, although vigilance to protect
against the risk of exacerbation of psychosis with some antidepressants
is important [II]. Mood stabilizers and beta-blockers
may be considered for reducing the severity of recurrent hostility and
aggression [II]. Careful attention must be paid
to potential drug-drug interactions, especially those related to
metabolism by cytochrome P450 enzymes [I].
Psychosocial interventions in the acute phase are aimed at
reducing overstimulating or stressful relationships, environments,
or life events and at promoting relaxation or reduced arousal through simple,
clear, coherent communications and expectations; a structured and
predictable environment; low performance requirements; and tolerant,
nondemanding, supportive relationships with the psychiatrist and
other members of the treatment team. Providing information to the
patient and the family on the nature and management of the illness
that is appropriate to the patient's capacity to assimilate
information is recommended [II]. Patients can
be encouraged to collaborate with the psychiatrist in selecting
and adjusting the medication and other treatments provided [II].
The acute phase is also the best time for the psychiatrist
to initiate a relationship with family members, who tend to be particularly
concerned about the patient's disorder, disability, and
prognosis during the acute phase and during hospitalization [I].
Educational meetings, "survival workshops" that
teach the family how to cope with schizophrenia, and referrals to
local chapters of patient and family organizations such as NAMI
may be helpful and are recommended [III].
Family members may be under considerable stress, particularly if
the patient has been exhibiting dangerous or unstable behavior.
During the stabilization phase, the goals of treatment are
to reduce stress on the patient and provide support to minimize
the likelihood of relapse, enhance the patient's adaptation
to life in the community, facilitate continued reduction in symptoms
and consolidation of remission, and promote the process of recovery.
If the patient has improved with a particular medication regimen,
continuation of that regimen and monitoring are recommended for
at least 6 months [I]. Premature lowering of dose
or discontinuation of medication during this phase may lead to a
recurrence of symptoms and possible relapse. It is also critical
to assess continuing side effects that may have been present in
the acute phase and to adjust pharmacotherapy accordingly to minimize
adverse side effects that may otherwise lead to medication nonadherence
and relapse [I].
Psychosocial interventions remain supportive but may be less
structured and directive than in the acute phase [III].
Education about the course and outcome of the illness and about
factors that influence the course and outcome, including treatment
adherence, can begin in this phase for patients and continue for
family members [II].
It is important that there be no gaps in service delivery,
because patients are particularly vulnerable to relapse after an
acute episode and need support in resuming their normal life and
activities in the community [I]. For hospitalized
patients, it is frequently beneficial to arrange an appointment
with an outpatient psychiatrist and, for patients who
will reside in a community residence, to arrange a visit before
discharge [II]. Adjustment to life in the community
for patients can be facilitated through realistic goal setting without
undue pressure to perform at high levels vocationally and socially,
since unduly ambitious expectations can be stressful and can increase
the risk of relapse [I]. While it is critical
not to place premature demands on the patient regarding engagement
in community-based activities and rehabilitation services,
it is equally critical to maintain a level of momentum aimed at improving
community functioning in order to instill a sense of hope and progress
for the patient and family [I].
The goals of treatment during the stable phase are to ensure
that symptom remission or control is sustained, that the patient
is maintaining or improving his or her level of functioning
and quality of life, that increases in symptoms or relapses are
effectively treated, and that monitoring for adverse treatment effects
continues. Regular monitoring for adverse effects is recommended [I].
If the patient agrees, it is helpful to maintain strong ties with
persons who interact with the patient frequently and would therefore
be most likely to notice any resurgence of symptoms and the occurrence
of life stresses and events that may increase the risk of relapse
or impede continuing functional recovery [II].
For most persons with schizophrenia in the stable phase, psychosocial
interventions are recommended as a useful adjunctive treatment to
pharmacological treatment and may improve outcomes [I].
Antipsychotic medications substantially reduce the risk of
relapse in the stable phase of illness and are strongly recommended [I].
Deciding on the dose of an antipsychotic medication during the stable
phase is complicated by the fact that there is no reliable strategy
available to identify the minimum effective dose to prevent relapse.
For most patients treated with first-generation antipsychotics,
a dose is recommended that is around the "extrapyramidal
symptom (EPS) threshold" (i.e., the dose that will induce
extrapyramidal side effects with minimal rigidity detectable on
physical examination), since studies indicate that higher doses
are usually not more efficacious and increase the risk of subjectively
intolerable side effects [II]. Lower doses of
first-generation antipsychotic medications may be associated with
improved adherence and better subjective state and perhaps ultimately
better functioning. Second-generation antipsychotics can generally
be administered at doses that are therapeutic yet well below the "EPS
threshold." The advantages of decreasing antipsychotic
doses to minimize side effects can be weighed against the disadvantage
of a somewhat greater risk of relapse and more frequent exacerbations
of schizophrenic symptoms. In general, it is more important to prevent
relapse and maintain the stability of the patient [III].
The available antipsychotic medications are associated with
differential risk of a variety of side effects, including neurological,
metabolic, sexual, endocrine, sedative, and cardiovascular side effects.
Monitoring of side effects based on the side effect profile of the
prescribed antipsychotic is warranted. During the stable phase of
treatment it is important to routinely monitor all patients treated with
antipsychotics for extrapyramidal side effects and the development
of tardive dyskinesia [I]. Because of the risk
of weight gain associated with many antipsychotics, regular measurement
of weight and body mass index (BMI) is recommended [I].
Routine monitoring for obesity-related health problems (e.g., high
blood pressure, lipid abnormalities, and clinical symptoms of diabetes) and
consideration of appropriate interventions are recommended particularly
for patients with BMI in the overweight and obese ranges [II].
Clinicians may consider regular monitoring of fasting glucose or
hemoglobin A1c levels to detect emerging diabetes, since patients
often have multiple risk factors for diabetes, especially patients
with obesity [I].
Antipsychotic treatment often results in substantial improvement
or even remission of positive symptoms. However, most patients remain
functionally impaired because of negative symptoms, cognitive deficits,
and limited social function. It is important to evaluate whether residual
negative symptoms are in fact secondary to a parkinsonian syndrome
or untreated major depression, since interventions are available
to address these causes of negative symptoms [II].
Most patients who develop schizophrenia and related psychotic
disorders are at very high risk of relapse in the absence of antipsychotic
treatment. Unfortunately, there is no reliable indicator to differentiate
the minority who will not from the majority who will relapse with
drug discontinuation. It is important to discuss with the patient
the risks of relapse versus the long-term potential risks of maintenance
treatment with the prescribed antipsychotic [I].
If a decision is made to discontinue antipsychotic medication, additional
precautions to minimize the risk of a psychotic relapse are warranted.
Educating the patient and family members about early signs of relapse,
advising them to develop plans for action should these signs appear,
and encouraging the patient to attend outpatient visits on a regular
basis are warranted [I]. Indefinite maintenance
antipsychotic medication is recommended for patients who have had
multiple prior episodes or two episodes within 5 years [I]. In
patients for whom antipsychotic medications have been
prescribed, monitoring for signs and symptoms of impending or actual
relapse is recommended [I].
Adjunctive medications are commonly prescribed for comorbid
conditions of patients in the stable phase. Comorbid major depression
and obsessive-compulsive disorder may respond to antidepressant medications [II].
Mood stabilizers may also address prominent mood lability [II].
Benzodiazepines may be helpful for managing anxiety and insomnia
during the stable phase of treatment [II].
In assessing treatment resistance or partial response, it
is important to carefully evaluate whether the patient has had an
adequate trial of an antipsychotic medication, including whether
the dose is adequate and whether the patient has been taking the
medication as prescribed. An initial trial of 4–6 weeks
generally is needed to determine if the patient will have any symptomatic
response, and symptoms can continue to improve over 6 months or
even longer periods of antipsychotic treatment [II].
Given clozapine's superior efficacy, a clozapine trial
should be considered for a patient who has had no response or partial
and suboptimal response to two trials of antipsychotic medication
(at least one second-generation agent) or for a patient with persistent
suicidal ideation or behavior that has not responded to other treatments [I].
A number of psychosocial treatments have demonstrated effectiveness
during the stable phase. They include family intervention [I],
supported employment [I], assertive community
treatment [I], skills training [II],
and cognitive behaviorally oriented psychotherapy [II].
In the same way that psychopharmacological management must be individually
tailored to the needs and preferences of the patient, so too should
the selection of psychosocial treatments [I].
The selection of appropriate psychosocial treatments is guided by
the circumstances of the individual patient's needs and
social context [II].
Interventions that educate family members about schizophrenia
are needed to provide support and offer training in effective problem
solving and communication, reduce symptom relapse, and contribute
to improved patient functioning and family well-being [I].
The Program for Assertive Community Treatment (PACT) is a specific
model of community-based care that is needed to treat patients who
are at high risk for hospital readmission and who cannot be maintained
by more usual community-based treatment [I]. Persons
with schizophrenia who have residual psychotic symptoms while receiving
adequate pharmacotherapy also may be offered cognitive behaviorally
oriented psychotherapy [II].
Supported employment is an approach to improve vocational
functioning among persons with various types of disabilities, including
schizophrenia, and should be made available [I].
The evidence-based supported employment programs that have been
found effective include the key elements of services focused on
competitive employment, eligibility based on the consumer's
choice, rapid job search, integration of rehabilitation and mental
health care, attention to the consumer's preferences, and
time-unlimited and individualized support.
Social skills training may be helpful in addressing functional
impairments with social skills or activities of daily living [II].
The key elements of this intervention include behaviorally based instruction,
modeling, corrective feedback, and contingent social reinforcement.
Treatment programs need to combine medications with a range
of psychosocial services to reduce the need for crisis-oriented
hospitalizations and emergency department visits and enable greater recovery [I].
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G. Other Specific Treatment Issues
It is important to treat schizophrenia in its initial episode
as soon as possible [II]. When a patient presents
with a first-episode psychosis, close observation and documentation
of the signs and symptoms over time are important because first
episodes of psychosis can be polymorphic and evolve into a variety
of specific disorders (e.g., schizophreniform disorder,
bipolar disorder, schizoaffective disorder) [I].
Furthermore, in persons who meet the criteria for being prodromally
symptomatic and at risk for psychosis in the near future, careful
assessment and frequent monitoring are recommended until symptoms
remit spontaneously, evolve into schizophrenia, or evolve
into another diagnosable and treatable mental disorder [III].
The majority of first-episode patients are responsive
to treatment, with more than 70% achieving remission
of psychotic signs and symptoms within 3–4 months and 83% achieving
stable remission at the end of 1 year. First-episode patients are
generally more sensitive to the therapeutic effects and side effects
of medications and often require lower doses than patients with
chronic schizophrenia. Minimizing risk of relapse in a remitted
patient is a high priority, given the potential clinical, social,
and vocational costs of relapse [I]. Family members
are especially in need of education and support at the time of the
patient's first episode [I].
Treatment of negative symptoms begins with assessing the patient
for syndromes that can cause the appearance of secondary negative
symptoms [I]. The treatment of such secondary
negative symptoms consists of treating their cause, e.g., antipsychotics
for primary positive symptoms, antidepressants for depression, anxiolytics
for anxiety disorders, or antiparkinsonian agents or antipsychotic
dose reduction for extrapyramidal side effects [III].
If negative symptoms persist, they are presumed to be primary negative
symptoms of the deficit state. There are no treatments with proven
efficacy for primary negative symptoms.
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3. Substance use disorders
Nearly one-half of patients with schizophrenia have comorbid
substance use disorders, excluding nicotine abuse/dependence,
which itself exceeds 50% in prevalence in this group. The
goals of treatment for patients with schizophrenia who also have
a substance use disorder are the same as those for treatment of
patients with schizophrenia without comorbidity but with the addition
of the goals for the treatment of substance use disorders, e.g.,
harm reduction, abstinence, relapse prevention, and rehabilitation.
A comprehensive integrated treatment model is recommended in which
the same clinicians or team of clinicians provide treatment for
schizophrenia as well as treatment of substance use disorders [III].
This form of treatment features assertive outreach, case management, family
interventions, housing, rehabilitation, and pharmacotherapy. It
also includes behavioral interventions for those who are trying
to attain or maintain abstinence and a stage-wise motivational approach
for patients who do not recognize the need for treatment of a substance
use disorder.
Depressive symptoms are common at all phases of schizophrenia.
A careful differential diagnosis that considers the contributions
of side effects of antipsychotic medications, demoralization, the negative
symptoms of schizophrenia, and substance intoxication or withdrawal
is recommended [I]. Depressive symptoms that occur
during the acute psychotic phase usually improve as patients recover from
the psychosis. There is also evidence to suggest that depressive
symptoms are reduced by antipsychotic treatment, with comparison
trials finding that second-generation antipsychotics may have
greater efficacy for depressive symptoms than first-generation antipsychotics [II].
Antidepressants may be added as an adjunct to antipsychotics when
the depressive symptoms meet the syndromal criteria for major depressive
disorder or are severe, causing significant distress or interfering
with function [II].
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5. Suicidal and aggressive behaviors
Suicide is the leading cause of premature death among patients
with schizophrenia. Some risk factors for suicide among patients
with schizophrenia are the same as those for the general population: male
gender, white race, single marital status, social isolation, unemployment,
a family history of suicide, previous suicide attempts, substance
use disorders, depression or hopelessness, and a significant recent
adverse life event. Specific demographic risk factors for suicide
among persons with schizophrenia are young age, high socioeconomic
status background, high IQ with a high level of premorbid scholastic
achievement, high aspirations and expectations, early age at onset/first hospitalization,
a chronic and deteriorating course with many relapses, and greater
insight into the illness.
Despite identification of these risk factors, it is not possible
to predict whether an individual patient will attempt suicide or
die by suicide. It is important to consider suicide risk at all
stages of the illness and to perform an initial suicide risk assessment
and regular evaluation of suicide risk as part of each patient's
psychiatric evaluation [I]. There is evidence
to suggest that both first- and second-generation antipsychotic
medications may reduce the risk of suicide. However, clozapine is
the most extensively studied and has been shown to reduce the rates
of suicide [II] and persistent suicidal behavior [I].
During a hospitalization, use of suicide precautions and careful
monitoring over time for suicidal patients are essential [I].
Upon discharge, the patient and the family members may be advised
to look for warning signs and to initiate specific contingency plans
if suicidal ideation recurs [I]. After a recent
discharge from the hospital, a higher frequency of outpatient visits
is recommended, and the number of visits may need to be increased
during times of personal crisis, significant environmental changes,
heightened distress, or deepening depression during the course of
illness [III].
A minority of patients with schizophrenia have an increased
risk for aggressive behavior. The risk for aggressive behavior increases
with comorbid alcohol abuse, substance abuse, antisocial personality,
or neurological impairment. Identifying risk factors for aggressive
behavior and assessment of dangerousness are part of a standard
psychiatric evaluation [I].
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H. Treatment Settings and Housing Options
Patients with schizophrenia may receive care in a variety
of settings. In general, patients should be cared for in the least
restrictive setting that is likely to be safe and to allow for effective
treatment [I]. Indications for hospitalization
usually include the patient's being considered to pose
a serious threat of harm to self or others or being unable to care
for self and needing constant supervision or support [I].
Other possible indications for hospitalization include general medical
or psychiatric problems that make outpatient treatment unsafe or
ineffective [III] or new onset of psychosis [III]. Efforts
should be made to hospitalize such patients voluntarily [I].
Treatment programs that emphasize highly structured behavioral
techniques, including a token economy, point systems, and skills
training that can improve patients' functioning, are recommended for
patients with treatment-resistant schizophrenia who require long-term
hospitalization [I].
When it is uncertain whether the patient needs to be hospitalized,
alternative treatment in the community, such as day hospitalization,
home care, family crisis therapy, crisis residential care, or assertive
community treatment, should be considered [III].
Day hospitalization can be used as an immediate alternative to inpatient
care for acutely psychotic patients or used to continue stabilization after
a brief hospital stay [III].
Day treatment programs can be used to provide ongoing supportive
care for marginally adjusted patients with schizophrenia in the
later part of the stabilization phase and the stable phase of illness, and
such programs are usually not time-limited [III].
The goals are to provide structure, support, and treatment to help
prevent relapse and to maintain and gradually improve the patient's
social functioning [III].
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II. Formulation and Implementation
of a Treatment Plan
Because schizophrenia is a chronic illness that affects 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) enable recovery by
assisting patients in attaining personal life goals (e.g., in work,
housing, and relationships). For purposes of presentation throughout
this guideline, the course of treatment for persons with
schizophrenia is divided into three phases: acute, stabilization,
and stable. The acute phase begins with a new onset or acute exacerbation
of symptoms and spans the period until these symptoms are reduced
to a level considered to be the patient's expected "baseline." The
stabilization period follows the acute phase and constitutes a time-limited transition
to continuing treatment in the stable phase. Combined, the acute
and stabilization phases generally span approximately 6 months.
The stable phase represents a prolonged period of treatment and
rehabilitation during which symptoms are under adequate control
and the focus is on improving functioning and recovery. While these
distinctions may be somewhat arbitrary, they provide a useful framework
for discussion of treatment.
Many of the advances in the treatment of schizophrenia over
the past two decades have come from recognition of the complexities
of the manifestations and the different stages of the illness. These insights
into the multiple components of psychopathology in schizophrenia
and into the role of family, social, and other environmental factors
in influencing both psychopathology and adaptation have resulted
in development of a wide range of treatments that target specific
aspects of the illness. Recognition of the different stages of the
illness has led to various approaches in treatment planning, treatment
selection, and drug dosing. Fragmentation of services and treatments
has long been a problem in delivering comprehensive care to persons
with schizophrenia. This fragmentation is determined by several
factors, including the use of many different treatment settings,
the necessary involvement of several professional disciplines, and
the use of multiple funding streams, coupled with inadequate insurance
coverage and the decline in funding for public and private mental
health services, to mention just a few. It is critical, under these
circumstances, that there be an overarching treatment plan that
serves the short- and long-term needs of the patient and that is
periodically modified as clinical circumstances change and new knowledge
about treatments becomes available.
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A. Psychiatric Management
This section is an overview of key issues in the psychiatric
management of patients with schizophrenia. It highlights areas that
research has shown to be important in affecting the course of illness
and success of treatment. These issues arise in the management of
all psychiatric illnesses. This section notes the particular ways
in which they occur in the treatment of patients with schizophrenia.
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1. Assessing symptoms and establishing a diagnosis
Effective and appropriate treatments are based on accurate,
relevant diagnostic and clinical assessments. In the case of schizophrenia,
the diagnosis has major implications for short- and long-term treatment
planning. (See Part B, Section IV.A, "Clinical Features," for
a description of the characteristic symptoms of schizophrenia and
the DSM-IV-TR criteria for diagnosis of the illness.) It is beyond
the scope of this guideline to discuss the differential diagnosis
of psychotic disorders and their evaluation. However, it is important
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.
Proper diagnosis, while essential, is insufficient to adequately
guide treatment of schizophrenia. Treatments are directed at the
manifestations and sequelae of schizophrenia. 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. Depression,
suicide, homelessness, substance use disorders, medical comorbidities,
social isolation, joblessness, criminal victimization, past sexual
or physical abuse, and involvement in the criminal justice system
are all far more common among persons with schizophrenia, particularly
in the chronic stages of the illness, than in the general population.
In addition to the core symptoms of schizophrenia, these areas need
careful assessment and, as warranted, appropriate interventions.
A number of objective, quantitative rating scales to monitor
clinical status in schizophrenia are available, as described in
the American Psychiatric Association's (APA's) Handbook
of Psychiatric Measures (1). They include the Structured
Clinical Interview for DSM-IV (2) for establishing diagnosis, the
Abnormal Involuntary Movement Scale (3) for monitoring tardive dyskinesia
and other abnormal movements, and the Brief Psychiatric Rating Scale
(BPRS) (4–6) and the Positive and Negative Syndrome Scale
(PANSS) (7) for monitoring psychopathology. Other brief structured
assessments are also available (8, 9). There are several reasons
that use of rating scales is important. First, rating scales provide
a record that documents the patient's response to treatment.
This record is of particular value when the treatment is nonstandard
(e.g., combination of antipsychotics) or expensive. Second, the
ratings can be compared with the patient's, family members',
and clinician's impressions of treatment effects and over
time can clarify the longitudinal course of the patient's
illness. This process can help temper excessive optimism when new
treatments are begun and can provide useful information about the actual
effects of prior treatments. Third, use of anchored scales with
criteria to assess the severity and frequency of symptoms helps
patients become more informed self-observers. Finally, use of the rating
scales over time ensures that information about the same areas is
collected at each administration and helps avoid omission of key
elements of information needed to guide treatment.
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2. Developing a plan of treatment
After the assessment of the patient's diagnosis and
clinical and psychosocial circumstances, a treatment plan must be
formulated and implemented. This process involves the selection
of the treatment modalities, specific type(s) of treatment, and
treatment setting. Depending on the acuity of the clinical situation
and because information about the patient's history and
from the clinical evaluation may only gradually become available,
this process can be iterative and evolve over the course of the
patient's association with the clinician. Indeed, formulation
and periodic reevaluation of the treatment plan at different phases
of implementation and stages of illness are essential to good clinical
practice. This process is described in greater detail in the subsequent
sections on the various phases of illness, treatment settings, and
types of treatments.
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3. Developing a therapeutic alliance and promoting
treatment adherence
It is essential for the psychiatrist who is treating the patient
to establish and maintain a supportive therapeutic alliance, which
forms the foundation on which treatment is conducted (10). Such
an 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 collaborate in treatment. To facilitate this
process, continuity of care with the same psychiatrist over time
is recommended, allowing the psychiatrist to learn more about the
patient as a person and the individual vicissitudes of the disorder over
time. However, while continuity is desirable, it does not ensure
quality, and continuity of inadequate treatment can be highly problematic.
Research indicates that specific attention in the therapeutic
relationship to identifying the patient's goals and aspirations
and relating them to treatment outcomes increases treatment
adherence (11). Moreover, evidence supports the conclusion that
the most effective medication adherence strategies focus on the
patient's attitudes and behaviors with respect to medication
rather than taking a general psychoeducational approach (12).
Not uncommonly, patients with schizophrenia stop taking medications,
miss clinic appointments, fail to report essential information to
their psychiatrists, and otherwise choose to not participate in recommended
treatments. To address partial or full treatment nonadherence, the
clinician should first assess contributing factors. Potential factors
can be broadly conceptualized under the health belief model, which
assumes adherence behavior is dynamic and influenced by a patient's
beliefs about need for treatment, the potential risks and benefits
of treatment, barriers to treatment, and social support for adhering
to treatment (13). Frequent causes of poor adherence are lack of
insight (14), breakdown of the therapeutic alliance, discrimination
associated with the illness, cultural beliefs, failure to understand
the need to take daily medication even in the stable phase, cognitive
impairment (15, 16), and experience of unpleasant medication side
effects such as akathisia (17, 18). Most patients have some ambivalence
about taking antipsychotic medications, all of which can be associated
with unpleasant and, rarely, dangerous side effects. Even patients
with good insight into their symptoms or illness may not perceive
their prescribed medication as potentially or actually helpful.
Patients who do experience troublesome or serious side effects may
decide that these effects outweigh the benefits of medication. Finally,
people important to the patient, including family and friends, may
discourage the patient from taking medication or participating in
other aspects of treatment.
Once the reasons for incomplete adherence are understood,
clinical interventions can be implemented to address them. For example,
encouraging the patient to report side effects and attempting to
diminish or eliminate them can significantly improve medication
adherence. Also, it is important for patients who are relatively
asymptomatic in the stable phase to understand that medication may be
prophylactic in preventing relapse (19, 20). If a patient stops
taking medication during the stable phase, he or she may feel better,
with less sedation or other side effects. As a result, the patient
may come to the false conclusion that the medication is not necessary
or does not have benefits. As will be described in later sections, psychotherapeutic
techniques based on motivational interviewing and cognitive behavior
techniques may enhance insight and treatment adherence. In situations
in which patients choose not to adhere to prescribed psychosocial
interventions, a careful review of the patient's perceptions
of the goals of the treatment and its likelihood for success is recommended.
The clinician may also help to identify practical barriers
to adherence, such as cognitive impairments or disorganization that
interferes with a willing patient's regular taking of medication
or participation in treatment. Use of simple aids, such as a pillbox
placed in a prominent location in the home and a watch with an alarm,
can enhance adherence. Family members and significant others can
also be involved, for example, by helping the patient fill the pillbox
and by regularly monitoring adherence. Patients without health care
insurance may have difficulty affording even generic antipsychotics
or basic psychosocial services. The clinician may help with access
to medications by suggesting and completing the physician's
sections of the application for patients' assistance programs
offered by most pharmaceutical companies. Some patients may not
have transportation to the pharmacy or to physician appointments
and other treatment services. For patients who are parents, lack
of child care may also pose a barrier to attending appointments.
For some patients, medication with a longer elimination half-life
or long-acting injectable medications are options that may improve
treatment adherence or minimize nonadherence. It is also important
to note that the half-lives of oral antipsychotic medications vary
widely. For patients who are prone to forget doses or are intermittently
nonadherent to treatment, drugs with slower rates of metabolism
may be used preferentially.
When a patient does not appear for appointments or is nonadherent
in other ways, assertive outreach, including telephone calls and
home visits, when appropriate, may be very helpful in reengaging
the patient in treatment. This outreach can be carried out by the
psychiatrist or other designated team member (e.g., of an assertive
community treatment team), when available, in consultation with
the psychiatrist. For some patients, nonadherence with care is frequent
and is associated with repeated cycles of decompensation and rehospitalization.
Particularly for patients who pose ongoing risks to self or others
as a result of nonadherence, many states now have programs available
for mandatory outpatient treatment (sometimes referred to as outpatient
commitment). Although some have questioned whether mandatory outpatient
treatment increases patients' reluctance to seek help voluntarily (21–23),
a growing body of evidence suggests that a number of benefits may
occur with mandatory outpatient treatment for appropriately selected
patients when it incorporates intensive individualized outpatient
services for an extended period of time. In addition to enhanced
adherence, most (24–27) but not all (28) studies show mandatory
outpatient treatment to be associated with benefits, including reductions in
substance use and abuse, decreases in violent incidents, reductions
in the likelihood of being criminally victimized, and improvements
in quality of life in appropriately targeted patients. Thus, for
a small subgroup of patients with repeated relapses and rehospitalizations
associated with nonadherence, mandatory outpatient treatment can
be a useful approach to improved adherence and enhanced outcomes (29).
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4. Providing patient and family education and therapies
Working with patients to recognize early symptoms of relapse
can result in preventing full-blown illness exacerbations (30).
Family education about the nature of the illness and coping strategies
can markedly diminish relapses and improve quality of life for patients (31).
For general educational purposes, a variety of useful written materials
about schizophrenia is available. The interventions that have been
shown to be effective, however, involve face-to-face interactions
in individual or group sessions for a total of at least 9–12
months, with the availability of crisis intervention and problem-solving
tasks as a central element of the therapy.
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5. Treating comorbid conditions
As already noted, a number of psychiatric, social, and other
medical conditions occur far more frequently in persons with schizophrenia
than in the general population. Periodic assessment of these conditions
by the treatment team is important. Commonly co-occurring major
depression, substance use disorders, and PTSD are usually identifiable
through clinical examinations and discussions with the patient and significant
others, combined with longitudinal observation of the patient's
behavior patterns. Each of these conditions deserves attention and
possibly treatment in its own right, with such treatment concurrent
with that for schizophrenia. Substance use disorders, in particular, complicate
assessment and treatment of schizophrenia, but delaying treatment
of the psychotic disorder until the substance use disorder is under
control is not recommended, as untreated psychosis is likely to
be associated with increased substance use (32).
Section II.F.3, "Concurrent General Medical Conditions", discusses nonpsychiatric medical conditions that are commonly
comorbid with schizophrenia. Certain illnesses, such as diabetes,
are more common in persons with schizophrenia and have also been
associated with some second-generation antipsychotic medications.
Nicotine dependence is also common among persons with schizophrenia
and contributes to the increased risk of physical illnesses (33, 34). It is important that patients have access to primary care clinicians
who can work with the psychiatrist to diagnose and treat concurrent
general medical conditions and that the psychiatrist maintain competence
in screening for common medical conditions and for providing ongoing monitoring
and treatment of common medical conditions in conjunction with primary
care clinicians.
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6. Attending to the patient's social circumstances
and functioning
The social circumstances and functioning of the patient can
have profound effects on adherence and response to treatment. The
patient's living situation, family involvement, sources
and amount of income, legal status, and relationships with significant
others (including children) can both produce stress and be protective;
thus, all are areas where periodic exploration by mental health
care clinicians is warranted. A frequently neglected aspect of social
assessment is the parenting role of patients with children (35, 36). The patient's sexuality is also often not adequately
assessed, not only from the standpoint of adverse medication effects,
but in terms of sexual relations and practices.
Depending on the nature of the problem in the patient's
social circumstances, other mental health professionals may need
to be involved in achieving its resolution. 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. It is important that disability
income support is secured when indicated.
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7. Integrating treatments from multiple clinicians
Many patients with schizophrenia require a variety of treatments,
often from multiple clinicians. This requirement creates the potential
for fragmentation of treatment efforts for patients who frequently
have problems with planning and organizing. In many settings integration
of treatments is best accomplished through designation of treatment
teams, led by a psychiatrist or other skilled mental health professional,
that meet periodically to review progress and goals and
to identify obstacles to improvement. So-called case management,
which provides the patient assistance in gaining access to community
services and resources, is often useful to facilitate integration
of treatments. Either several members of a team or one person can
be assigned to be the case manager, ensuring that the patient receives
coordinated, continuous, and comprehensive services. For example, the
case manager may accompany the patient to a welfare agency, visit
the patient's home if a clinical appointment is missed,
or convene a meeting of workers from different agencies serving
the patient to formulate an overall treatment plan in conjunction
with the psychiatrist. There are a variety of educational and organizational
approaches to building teams and programs that facilitate the goal
of integrated treatment (37, 38).
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8. Documenting treatment
Whether treated in the private or public sector, most persons
with schizophrenia will have many different practitioners over the
course of their illness. These transitions result from changes in treatment
venues (inpatient, outpatient, assertive community treatment, etc.),
program availability, insurance, the patient's locale,
and clinic personnel. Because an accurate history of past and current treatments
and responses to them is a key ingredient to treatment planning,
excellent documentation is paramount. Especially critical, for example,
is information about prior medication trials, including doses, length
of time at specific doses, side effects, and clinical response.
Despite the importance of an accurate history, studies of the adequacy
of documentation (39) and clinical experience illustrate the extraordinary
difficulty encountered in efforts to piece together a coherent story
from the medical records of most patients with schizophrenia. Although actual
chart documentation is the responsibility of the individual
practitioner, it is typically the employing or contracting organization
that is in the best position to facilitate good documentation and
to effect periodic overviews of treatment. Appropriate documentation
of assessment of competency, informed consent for treatment, and
release of information also deserve careful attention by the clinician
and the treatment organization.
Within the organization there are at least two major issues
in information management. From the standpoint of information collection,
the organization and its practitioners need to agree on the critical elements
of information to obtain and the frequency with which they should
be obtained. Recording of information may occur contemporaneously
with collection or immediately thereafter. Labor-saving forms (paper
or computer-based) may help in prompting data collection and easing
its recording. Once information is collected, the ability to gain
access to the information is essential. Thus, the organization will
want to develop plans so that medical records will be available
whenever and wherever the patient is seen. In addition, if the patient's
care is transferred from one practitioner to another (e.g., outpatient
to inpatient), necessary information will need to be transferred
to the new practitioner ahead of or along with the patient. Release
of a patient's information will generally require the patient's
consent and should conform to applicable regulations and policies
(e.g., state law, the Health Insurance Portability and Accountability
Act, and Principles of Medical Ethics: With Annotations
Especially Applicable to Psychiatry[40]).
The goals of treatment during the acute phase of a psychotic
exacerbation 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. It is especially important to address
the anxiety, fear, and dysphoria commonly associated with
an acute episode. 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. 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. The main therapeutic challenge
for the clinician is to select and "titrate" the
doses of both pharmacological and psychosocial interventions in
accordance with the symptoms and sociobehavioral functioning of
the patient (41). It is important to emphasize that acute-phase
treatment is often but no longer necessarily associated with hospitalization.
With the growth of managed care restricting the use of hospitalization and
the development of alternative community-based programs, acute-phase
treatment frequently occurs outside of the hospital.
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1. Assessment in the acute phase
A thorough initial workup, including complete psychiatric
and general medical histories and physical and mental status examinations,
is recommended for all patients, as allowed by the patient's clinical
status. Interviews of family members or other persons knowledgeable
about the patient should 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. In
emergency circumstances, as when a patient's safety is
at risk, it may be necessary and permissible to speak with others
without the patient's consent.
When a patient is in an acute psychotic state, acutely agitated,
or both, it may be impossible to perform an adequate evaluation
at the time of the initial contact. With the patient's
consent, the psychiatrist may begin treatment with an appropriate
medication and perform the necessary evaluations as the patient's
condition improves and permits. For acutely psychotic or agitated
patients who lack the capacity or are unwilling to agree to receive
medication, state regulations on involuntary treatment should be
followed.
Some of the most common contributors to symptom relapse are
antipsychotic medication nonadherence, substance use, and stressful
life events (42–47). Medication adherence may be assessed
by the patient's report, the reports of family members
or other caregivers, pill counts, prescription refill counts, and,
for some medications, antipsychotic blood levels. Attention needs
to be given to potential drug-drug interactions that may affect
blood levels and hence toxicity and adherence. Useful guides for
determining potential adverse drug interactions related to the cytochrome
P450 enzyme system are now available (48, 49). The reason for nonadherence
should also 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. Substance
use should be routinely evaluated as part of the medical history
and with a urine toxicology screen. It is important to realize that
many drugs of abuse, including most designer drugs and hallucinogens,
are not detected by urine toxicology screens; if use of such substances
is suspected, a blood toxicology screen can detect some of them.
Withdrawal from alcohol or some other substances can present as
worsening psychosis, and the possibility of withdrawal should be
evaluated by medical history and vital sign monitoring in all patients
with acute exacerbation of symptoms. (The results of toxicology
screens will usually be negative, since risk of withdrawal is often
highest several days after abstinence from chronic abuse.) Body
weight and vital signs (heart rate, blood pressure, temperature)
should be measured. A CT or MRI scan may provide helpful information,
particularly in assessing patients with a new onset of psychosis
or with an atypical clinical presentation. Although imaging studies
cannot establish a diagnosis of schizophrenia, specific findings
from a CT or MRI scan (e.g., ventricular enlargement, diminished
cortical volume) may enhance the confidence of the diagnosis and
provide information that is relevant to treatment planning and prognosis.
Given the subtle nature of the neuropathological findings in schizophrenia,
MRI is preferred over CT.
Table 1 delineates suggested laboratory tests
for evaluating health status, including studies that may be indicated
when the clinical picture is unclear or when there are abnormal
findings on routine examination, as well as suggested methods to
monitor for side effects of treatment.
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These tests may detect occult disease that is contributing
to psychosis and also determine if there are comorbid medical conditions
that might affect medication selection, such as impaired liver or renal
function. Tests to assess other general medical needs of patients
should also be considered (e.g., gynecological examination, mammogram,
and rectal examination) (54). The U.S. Preventive Services Task
Force has reviewed the evidence of effectiveness and developed recommendations
for clinical preventive services (http://www.ahcpr.gov/clinic/uspstfix.htm).
It is also important that special precautions be taken in
the presence of suicidal ideation or intent or a suicide plan, including
an assessment of risk factors such as prior attempts, depressed
mood, and suicidal ideation, which are the best predictors of a
subsequent suicide attempt in schizophrenia (55, 56). Other predictors
of suicide that also warrant close attention include the presence
of command hallucinations, hopelessness, anxiety, extrapyramidal
side effects, and an alcohol or other substance use disorder. Similar
evaluations are necessary in considering the likelihood of dangerous
or aggressive behavior and whether the person will harm someone
else or engage in other forms of violence (57). The coexistence
of substance use (58) significantly increases the risk of violent
behavior. Because past behavior best predicts future behavior, family
members and friends are often helpful in determining the risk of
a patient's harming self or others and in assessing the
patient's ability for self-care.
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2. Psychiatric management in the acute phase
Psychosocial interventions in the acute phase are aimed at
reducing overstimulating or stressful relationships, environments,
or life events and at promoting relaxation or reduced arousal through simple,
clear, coherent communication and expectations; a structured and
predictable environment; low performance requirements; and tolerant,
nondemanding, supportive relationships with the psychiatrist and
other members of the treatment team.
The patient should be provided information on the nature and
management of the illness that is appropriate to his or her ability
to assimilate information. The patient should also be encouraged
to collaborate with the psychiatrist in selecting and adjusting
the medication and other treatments provided. Ordinarily, a hospitalized
patient should be provided with some information about the disorder
and the medications being used to treat it, including their benefits
and side effects. As described in Section II.A.3, "Developing
a Therapeutic Alliance and Promoting Treatment Adherence",
the psychiatrist must realize that the degree of acceptance of medication
and information about it will vary according to the patient's
cognitive capacity, the extent of the patient's insight,
and efforts made by the psychiatrist to engage the patient and the patient's
family members in a collaborative treatment relationship.
The acute phase is also the best time for the psychiatrist
to initiate a relationship with family members, who tend to be particularly
concerned about the patient's disorder, disability, and
prognosis during this phase and during hospitalization.
Educational meetings, "survival workshops" that
teach the family how to cope with schizophrenia, and referrals to
the local chapter of NAMI may be helpful. The NAMI web site (http://www.nami.org)
offers a wealth of useful information. Manuals, workbooks, and videotapes
are also available to aid families in this process (59–64).
Active efforts to involve relatives in treatment planning and implementation
are often a critical component of treatment.
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3. Use of antipsychotic medications in the acute
phase
Treatment with antipsychotic medication is indicated for nearly
all episodes of acute psychosis in patients with schizophrenia.
In this guideline the term "antipsychotic" refers
to several classes of medications (Table 2). These
include the first-generation antipsychotic medications and the second-generation
(sometimes referred to as "atypical") agents clozapine,
risperidone, olanzapine, quetiapine, ziprasidone, and
aripiprazole.
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Pharmacological treatment should be initiated as soon as is
clinically feasible, because acute psychotic exacerbations are associated
with emotional distress, disruption to the patient's life,
and a substantial risk of behaviors that are dangerous to self,
others, or property (57, 68, 69). There are limited circumstances
where it may be appropriate to delay treatment, for example, for
patients who require more extensive or prolonged diagnostic evaluation,
who refuse medications, or who may experience a rapid recovery because
substance use or acute stress reactions are thought to be the potential
cause of the symptom exacerbation.
Before treatment with antipsychotic medication is begun, baseline
laboratory studies may be indicated, if they have not already been
obtained as a part of the initial assessment (Table 1). In addition,
the treating physician should, as is feasible, discuss the potential
risks and benefits of the medication with the patient. The depth
of this discussion will, of course, be determined by the patient's condition.
Even with agitated patients and patients with thought disorder,
however, the therapeutic alliance will be enhanced if the patient
and physician can identify target symptoms (e.g., anxiety, poor
sleep, and, for patients with insight, hallucinations and delusions)
that are subjectively distressing and that antipsychotics can ameliorate.
Acute side effects such as orthostatic hypotension, dizziness, and
extrapyramidal side effects, including dystonic reactions, insomnia,
or sedation, should be discussed at this stage, leaving discussion
of long-term side effects to when the acute episode is resolving.
Mentioning the possibility of acute side effects helps patients
to identify and report their occurrence and also may help maintain
a therapeutic alliance. To the extent possible, it is important to
minimize acute side effects of antipsychotic medications, such as
dystonia, that can significantly influence a patient's
willingness to accept and continue pharmacological treatment. Patients
with schizophrenia often have attentional and other cognitive impairments
that may be more severe during an acute illness exacerbation, and
so it is often helpful to return to the topic of identifying target symptoms
and risk of acute side effects multiple times during the course
of hospitalization.
Rapid initiation of emergency treatment is needed when an
acutely psychotic patient is exhibiting aggressive behaviors toward
self, others, or objects. When the patient is in an emergency department, inpatient
unit, or other acute treatment facility, existing therapeutic protocols usually
define the appropriate response. Most of these protocols
recognize that the patient is usually frightened and confused and
that the first intervention involves staff members talking to the
patient in an attempt to calm him or her. Attempts to restrain the
patient should be done only by a team trained in safe restraint procedures
to minimize risk of harm to patients or staff (70). Antipsychotics
and benzodiazepines are often helpful in reducing the patient's
level of agitation (71). If the patient will take oral medication,
rapidly dissolving forms of olanzapine and risperidone can be used
for quicker effect and to reduce nonadherence. If a patient refuses
oral medication, most states allow for emergency administration
despite the patient's objection. Short-acting parenteral formulations
of first- and second-generation antipsychotic agents (e.g., haloperidol,
ziprasidone, and olanzapine), with or without a parenteral benzodiazepine
(e.g., lorazepam), are available for emergency administration in
acutely agitated patients (72–79). Use of rapidly dissolving
oral formulations of second-generation agents (e.g., olanzapine, risperidone)
or oral concentrate formulations (e.g., risperidone, haloperidol)
may also be useful for acute agitation. Other medications, such
as droperidol, can be used in selected clinical situations of extreme
emergency or in highly agitated patients (80). However, if droperidol
is used, its potential for cardiac rhythm disturbances must be considered, as
indicated in its labeling by a black-box warning for QTc prolongation.
In nonemergency circumstances in which the patient is refusing
medication, the physician may have limited options. When
a patient refuses medication, it is often helpful to enlist family
members as allies in helping the patient to accept medication. Often,
patients can be helped to accept pharmacological treatment over
time and with psychotherapeutic interactions that are
aimed toward identifying subjectively distressing symptoms that
have previously responded to treatment (12). Clinicians are encouraged
to make greater use of the option of advance directives by patients
in states where this option is available. Advance directives allow
competent patients to state their preferences about treatment choices
in the event of future decompensation and acute incapacity to make
decisions. Depending on prevailing state laws, when treatment measures
instituted on the basis of an advance directive fail, pharmacological
treatment may be administered involuntarily even in the absence
of acute dangerousness (81). In other instances, depending on state
laws, a judicial hearing may need to be sought for permission to
treat a patient who lacks capacity.
The process for determining pharmacological treatment in the
acute phase is shown in Table 3 and Figure 1.
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The selection of an antipsychotic medication is frequently
guided by the patient's previous experience with antipsychotics,
including the degree of symptom response, the side effect profile (including
past experience of side effects such as dysphoria), and the patient's
preferences for a particular medication, including the route of
administration. The second-generation antipsychotics should be considered
as first-line medications for patients in the acute phase of schizophrenia,
mainly because of the decreased risk of extrapyramidal side effects
and tardive dyskinesia (82–85), with the understanding
that there continues to be debate over the relative advantages,
disadvantages, and cost-effectiveness of first- and second-generation
agents (86–89). For patients who have been treated successfully
in the past or who prefer first-generation agents, these medications
are clinically useful and for specific patients may be the first
choice. With the possible exception of clozapine for patients with
treatment-resistant symptoms, antipsychotics generally
have similar efficacy in treating the positive symptoms of schizophrenia,
although there is emerging evidence and ongoing debate that second-generation
antipsychotics may have superior efficacy in treating global psychopathology
and cognitive, negative, and mood symptoms. To date, there is no
definitive evidence that one second-generation antipsychotic will
have superior efficacy compared with another, although in an individual
patient there may be clinically meaningful differences in response (89).
A patient's past history of side effects can guide antipsychotic
drug selection, since there is considerable difference in side effect
profiles among the available antipsychotics. Table 4 lists the relative
frequency of some adverse effects associated with selected antipsychotic
medications. Strategies for the monitoring and clinical management
of selected side effects of antipsychotic medications are outlined
in Table 1 and discussed in detail in Part B, Section V.A.1, "Antipsychotic Medications."
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While many patients prefer oral medication, patients with
recurrent relapses related to partial or full nonadherence are candidates
for a long-acting injectable antipsychotic medication,
as are patients who prefer the injectable formulation (91). If a
long-acting injectable medication is indicated, the oral form of
the same medication (i.e., fluphenazine, haloperidol,
and risperidone in the United States) is the logical choice for
initial treatment during the acute phase. The transition from oral
to long-acting injectable medication can begin during the acute
phase; however, the long-acting injectable agents are
not usually prescribed for acute psychotic episodes because
these medications can take months to reach a stable steady state and
are eliminated very slowly (92). As a result, the psychiatrist has
relatively little control over the amount of medication the patient is
receiving, and it is difficult to titrate the dose to control side
effects and therapeutic effects. There may, however, be circumstances
when it is useful to prescribe long-acting medications during acute treatment.
For example, if a patient experiences an exacerbation of psychotic
symptoms while receiving long-acting injectable medications, it
may be useful to continue the long-acting injectable medication
while temporarily supplementing it with oral medication (92).
Determining the optimal dose of antipsychotic medication in
the acute phase is complicated by the fact that there is usually
a delay between initiation of treatment and full therapeutic response. Patients
may take between 2 and 4 weeks to show an initial response (93) and
up to 6 months or longer to show full or optimal response. It is
important to select a dose that is both effective and not likely
to cause side effects that are subjectively difficult to tolerate,
since the experience of unpleasant side effects may affect long-term
adherence (see Section II.A.3, "Developing a Therapeutic
Alliance and Promoting Treatment Adherence"). Some common early side effects such as sedation,
postural hypotension, acute dystonia, or nausea will typically improve
or resolve after the first several days or weeks of treatment, and
patients can be encouraged to tolerate or temporarily manage these
short-term effects. Other side effects, notably akathisia and parkinsonism,
are likely to persist with long-term treatment. In general, the
optimal dose (range) of medication is that which produces maximal
therapeutic effects and minimal side effects. The optimal dose of
first-generation antipsychotics (Table 2) is, for most
patients, at the "EPS threshold," the dose that
will induce extrapyramidal side effects and where a physical examination
of the patient shows minimal rigidity (94). Evidence suggests that
doses above this threshold increase risk of extrapyramidal and other
side effects without enhancing efficacy (95–97). Second-generation
antipsychotics can generally be administered at doses
that are therapeutic yet well below the "EPS threshold." The
target dose (Table 2) usually falls within the therapeutic dose range
specified by the manufacturer and in the package labeling approved
by the U.S. Food and Drug Administration (FDA). In clinical practice,
however, doses of several second-generation drugs, including olanzapine,
quetiapine, and ziprasidone, have extended above their recommended
ranges. In determining the target dose, the psychiatrist should
consider the patient's past history of response and dose
needs, clinical condition, and severity of symptoms. Doses should
be titrated as quickly as tolerated to the target therapeutic dose
(generally sedation, orthostatic hypotension, and tachycardia are
the side effects that limit the rate of increase), and unless there
is evidence that the patient is having uncomfortable side
effects, the patient's clinical status ideally should then
be monitored for 2–4 weeks before increasing the dose or
changing medications. During these weeks it is often important for
the physician to be patient and avoid the temptation to prematurely
escalate the dose for patients who are responding slowly. Rapid
escalation can create the false impression of enhanced efficacy
when time is often an important factor, and higher doses may actually
be detrimental.
If the patient is not improving, consider whether the lack
of response can be explained by medication nonadherence, rapid medication
metabolism, or poor absorption. If the patient has been treated
with one of the medications for which there are adequate data on
blood level relationships with clinical response (e.g., clozapine,
haloperidol), determination of the plasma concentration may be helpful.
If nonadherence is a problem, behavioral tailoring (i.e., fitting
taking medication into one's daily routine) (30), motivational
interviewing, and other psychotherapeutic techniques may be useful
in helping the patient develop an understanding of the
potential benefits of medication (12, 98). In addition, surreptitious
nonadherence (i.e., "cheeking") may be addressed
by use of a liquid (e.g., risperidone, haloperidol), a quick-dissolving
tablet (e.g., olanzapine, risperidone), or a short-acting intramuscular
form (e.g., ziprasidone, haloperidol).
If the patient is adhering to treatment and has an adequate
plasma concentration of medication but is not responding to the
treatment, alternative treatments should be considered. If the patient
is able to tolerate a higher dose of antipsychotic medication without
significant side effects, raising the dose for a finite period,
such as 2–4 weeks, can be tried, although the incremental
efficacy of higher doses has not been well established. If dose
adjustment does not result in an adequate response, a different
antipsychotic medication should be considered.
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4. Use of adjunctive medications in the acute phase
Other psychoactive medications are commonly added to antipsychotic
medications in the acute phase to treat comorbid conditions or associated
symptoms (e.g., agitation, aggression, affective symptoms), to address
sleep disturbances, and to treat antipsychotic drug side effects.
Therapeutic approaches to treatment resistance and residual symptoms
are discussed in Section II.E, "Special Issues
in Caring for Patients With Treatment-Resistant Illness".
Adjunctive medications are also commonly prescribed for residual
symptoms and comorbid conditions during the acute phase. For example,
benzodiazepines may be helpful in treating catatonia as well as
in managing both anxiety and agitation. The most agitated patients
may benefit from addition of an oral or a parenteral benzodiazepine
to the antipsychotic medication. Lorazepam has the advantage of
reliable absorption when it is administered either orally or parenterally (99).
There is some evidence that mood stabilizers and beta-blockers may
be effective in reducing the severity of recurrent hostility and
aggression (100–102). Major depression and obsessive-compulsive
disorder are common comorbid conditions in patients with schizophrenia
and may respond to an antidepressant. However, some antidepressants (those
that inhibit catecholamine reuptake) can potentially sustain or
exacerbate psychotic symptoms in some patients (103). Careful attention
must be paid to potential drug-drug interactions, especially those
related to the cytochrome P450 enzymes (48, 49).
Sleep disturbances are common in the acute phase, and while
controlled studies are lacking, there is anecdotal evidence that
a sedating antidepressant (e.g., trazodone, mirtazapine) or a benzodiazepine
sedative-hypnotic may be helpful.
Medications can be used to treat extrapyramidal side effects
(Table 5) and other side effects of antipsychotic medications that
are described in detail in Part B, Section V.A.1, "Antipsychotic Medications." Decisions
to use medications to treat side effects are driven by the severity
and degree of distress associated with the side effect and by consideration
of other potential strategies, including lowering the dose of the
antipsychotic medication or switching to a different antipsychotic
medication. The following factors should be considered in decisions
regarding the prophylactic use of antiparkinsonian medications in
acute-phase treatment: the propensity of the antipsychotic
medication to cause extrapyramidal side effects, the patient's
preferences, the patient's prior history of extrapyramidal
side effects, other risk factors for extrapyramidal side effects
(especially dystonia), and risk factors for and potential consequences
of anticholinergic side effects.
+
+
5. Use of ECT and other somatic therapies in the
acute phase
ECT in combination with antipsychotic medications may be considered
for patients with schizophrenia or schizoaffective disorder with
severe psychotic symptoms that have not responded to treatment with
antipsychotic agents. The efficacy of acute treatment with ECT in
patients with schizophrenia has been described in a number of controlled
trials as well as in multiple case series and uncontrolled studies (106–108).
The greatest therapeutic benefits appear to occur when ECT is administered
concomitantly with antipsychotic medications. The majority of studies,
including several randomized studies, have shown benefit from ECT
combined with first-generation antipsychotic agents (109–126).
More recent findings also suggest benefit from combined treatment
with ECT and second-generation antipsychotic medications (127–135).
However, given the clear benefits of clozapine in patients with
treatment-resistant psychotic symptoms, a trial of clozapine will
generally be indicated before acute treatment with ECT.
Clinical experience, as well as evidence from case series
and open prospective trials, suggests that ECT should also be considered
for patients with prominent catatonic features that have not responded to
an acute trial of lorazepam (136–143). For patients
with schizophrenia and comorbid depression, ECT may also be beneficial
if depressive symptoms are resistant to treatment or if features
such as suicidal ideation and behaviors or inanition, which necessitate
a rapid therapeutic response, are present.
For additional details on the assessment of patients before
ECT, the informed consent process, the technical aspects of ECT
administration, and the side effects associated with treatment,
the reader is referred to APA's The Practice
of Electroconvulsive Therapy: Recommendations for Treatment, Training,
and Privileging: A Task Force Report of the American Psychiatric
Association (107).
Although it has been suggested that repetitive transcranial
magnetic stimulation (rTMS) may share beneficial features of ECT (144, 145) and several recent studies with rTMS have shown promising results
in decreasing auditory hallucinations (146–148),
rTMS does not have an FDA indication for the treatment of psychosis,
and additional research is needed before recommending its use in
clinical practice.
During the stabilization phase, the aims of treatment are
to sustain symptom remission or control, minimize stress on the
patient, provide support to minimize the likelihood of relapse,
enhance the patient's adaptation to life in the community,
facilitate the continued reduction in symptoms and consolidation
of remission, and promote the process of recovery.
Controlled trials provide relatively little guidance for medication
treatment during this phase. If the patient has achieved an adequate
therapeutic response with minimal side effects or toxicity with a
particular medication regimen, he or she should be monitored while
taking the same medication and dose for the next 6 months. Premature
lowering of dose or discontinuation of medication during this phase
may lead to a relatively rapid relapse. However, it is also critical
to assess continuing side effects that may have been present in
the acute phase and to adjust pharmacotherapy accordingly to minimize
adverse side effects that may otherwise lead to medication nonadherence
and relapse. Moreover, any adjunctive medications that have been
used in the acute phase should be evaluated for continuation.
Psychotherapeutic interventions remain supportive but may
be less structured and directive than in the acute phase. Education
about the course and outcome of the illness and about factors that influence
the course and outcome, including treatment adherence, can begin
in this phase for patients and continue for family members. Educational
programs during this phase have been effective in teaching a wide
range of patients with schizophrenia the skills of medication self-management
(e.g., the benefits of maintenance antipsychotic medication, how
to cope with side effects) and symptom self-management (e.g., how
to identify early warning signs of relapse, develop a relapse prevention plan,
and refuse illicit drugs and alcohol), as well as strategies for
interacting with health care providers (149–152).
It is important that there be no gaps in service delivery,
because patients are vulnerable to relapse and need support in adjusting
to community life. Not uncommonly, problems in continuity of care arise
when patients are discharged from hospitals to community care. It
is imperative to arrange for linkage of services between hospital
and community treatment before the patient is discharged from the
hospital. Short lengths of hospital stay create challenges for adequately
linking inpatient to outpatient care, but to the extent possible,
patients should have input into selecting their postdischarge follow-up
residential and treatment plans. It is frequently beneficial to
arrange an appointment with an outpatient psychiatrist and, for
patients who will reside in a community residence, to arrange a visit
before discharge (153, 154). After discharge, patients should be
helped to adjust to life in the community through realistic goal
setting without undue pressure to perform at high levels vocationally
and socially, since unduly ambitious expectations on the part of
therapists (20), family members (155), or others, as well as an
overly stimulating treatment environment (156), can be stressful
to patients and can increase the risk of relapse. These principles
also apply in the stable phase. Efforts should be made to actively
involve family members in the treatment process. Other psychosocial
treatments, discussed in Section II.D, "Stable Phase"), may be initiated during this phase depending on the
patient's level of recovery and motivation. While it is critical
not to place premature demands on the patient regarding engagement
in community-based activities and rehabilitation services, it is
equally critical to maintain a level of momentum aimed at improving
community functioning in order to instill a sense of hope and progress
for the patient and family. These efforts set the stage for continuing
treatments during the stable phase.
Treatment during the stable phase is designed to sustain symptom
remission or control, minimize the risk and consequences of relapse,
and optimize functioning and the process of recovery.
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1. Assessment in the stable phase
Ongoing monitoring and assessment during the stable phase
are necessary to determine whether the patient might benefit from
alterations in the treatment program. Ongoing assessment allows patients
and those who interact with them to describe any changes in symptoms
or functioning and raise questions about specific symptoms and side
effects.
Monitoring for adverse effects should be done regularly (Table 1). Clinicians should inquire about the course of any side effects
that developed in the acute or stabilization phases (e.g., sexual
side effects, sedation). Monitoring for other potential adverse
effects should be guided by the particular medications chosen (see
Part B, Section V.A.1, "Antipsychotic Medications,"
If the patient agrees, it is helpful to maintain strong ties
with persons who interact with the patient frequently and would
therefore be most likely to notice any resurgence of symptoms and
the occurrence of life stresses and events that may increase the
risk of relapse or impede continuing functional recovery. However,
the frequency of assessments by the psychiatrist or other members
of the treatment team depends on the specific nature of the treatment
and expected fluctuations of the illness. Frequency of contacts
may range from every few weeks for patients who are doing well and are
stabilized to as often as every day for those who are going through
highly stressful changes in their lives.
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2. Psychosocial treatments in the stable phase
For most persons with schizophrenia in the stable phase, treatment
programs that combine medications with a range of psychosocial services
are associated with improved outcomes. Knowledge and research regarding
how best to combine treatments to optimize outcome are scarce. Nonetheless,
provision of such packages of services likely reduces
the need for crisis-oriented care hospitalizations and emergency
department visits and enables greater recovery.
A number of psychosocial treatments have demonstrated effectiveness.
These treatments include family interventions (31, 157, 158), supported
employment (159–162), assertive community treatment (163–166),
social skills training (167–169), and cognitive behaviorally
oriented psychotherapy (158, 170). An evidence-based practices project
sponsored by the Substance Abuse and Mental Health Services Administration
(SAMHSA) is developing resource kits on family interventions, assertive community
treatment, and supported employment (draft versions available at
http://mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/family/;
http://mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/community/;
http://mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/employment/).
In the same way that psychopharmacological management must
be individually tailored to the needs and preferences of the patient,
so too should the selection of psychosocial treatments. The selection
of appropriate and effective psychosocial treatments needs to be
driven by the circumstances of the individual patient's
needs and his or her social context. At the very least, all persons
with schizophrenia should be provided with education about their
illness. Beyond needing illness education, most patients will also
benefit from at least some of the recommended psychosocial interventions.
However, since patients' clinical and social needs will
vary at different points in their illness course and since some
psychosocial treatments share treatment components, it would be
rare for all of these psychosocial interventions to be utilized
during any one phase of illness for an individual patient.
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a) Prevention of relapse and reduction of symptom
severity
A major goal during the stable phase is to prevent relapse
and reduce the severity of residual symptoms. Certain psychosocial
interventions have demonstrated effectiveness in this regard. They include
family education and support, assertive community treatment, and
cognitive therapy.
Interventions that educate families about schizophrenia, provide
support, and offer training in effective problem solving and communication
have been subjected to numerous randomized clinical trials (171, 172). The data strongly and consistently support the value of such
interventions in reducing symptom relapse, and there is some evidence
that these interventions contribute to improved patient functioning and
family well-being. Randomized clinical trials have reported 2-year
relapse rates for patients receiving family "psychoeducation" programs
in combination with medication that are 50% lower than
those for patients receiving medication alone (173–180).
Further, a recent study found psychoeducational programs using multiple
family groups to be more effective and less expensive than individual
family psychoeducational interventions for Caucasians, though not
for African Americans (178). On the basis of the evidence, persons
with schizophrenia and their families who have ongoing contact with
each other should be offered a family intervention, the key elements
of which include a duration of at least 9 months, illness education,
crisis intervention, emotional support, and training in how to cope
with illness symptoms and related problems.
PACT is a specific model of community-based care. Its origin
is an experiment in Madison, Wisconsin, in the 1970s in which the
multidisciplinary inpatient team of the state hospital was moved into
the community (181, 182). The team took with it all of the functions
of an inpatient team: interdisciplinary teamwork, 24-hour/7-days-per-week
coverage, comprehensive treatment planning, ongoing responsibility,
staff continuity, and small caseloads. PACT is designed to treat
patients who are at high risk for hospital readmission and who cannot
be maintained by more usual community-based treatment as well as
for patients with severe psychosocial impairment who need extensive
assistance to live in the community. Randomized trials comparing
PACT to other community-based care have consistently shown that PACT
substantially reduces utilization of inpatient services and promotes
continuity of outpatient care (183, 184). Patients' satisfaction
with this model is generally high, and family advocacy groups, such
as NAMI in the United States, strongly support its use and dissemination.
Results are less consistent regarding the effect of PACT on
other outcomes, although at least some studies have shown enhancement
of clinical status, functioning, and quality of life. Cost-effectiveness studies
support its value in the treatment of high-risk patients. Studies
also indicate that a particular PACT program's effectiveness
is related to the fidelity with which it is implemented, that is,
the degree to which the program adheres to the original PACT model.
Controlled studies of cognitive behavior psychotherapy have
reported benefits in reducing the severity of persistent psychotic
symptoms (170). Most of the studies have been performed with individual
cognitive behavior therapy of at least several months' duration;
in some studies, group cognitive behavior therapy and/or
therapy of a shorter duration has been used. In all of the studies
clinicians who provided cognitive behavior therapy received specialized
training in the approach. In addition, the key elements of this
intervention include a shared understanding of the illness between
the patient and therapist, identification of target symptoms, and
the development of specific cognitive and behavioral strategies
to cope with these symptoms. Therefore, based on the available evidence,
persons with schizophrenia who have residual psychotic symptoms
while receiving adequate pharmacotherapy may benefit from cognitive behaviorally
oriented psychotherapy.
A variety of other approaches to counseling individual patients
to help them cope better with their illness are used, although research
in this area remains limited. In general, counseling that emphasizes illness
education, support, and problem solving is most appropriate. A notable
prototype of this approach is personal therapy, as developed by
Hogarty and colleagues (185–187). Personal therapy is an
individualized long-term psychosocial intervention provided to patients on
a weekly to biweekly frequency within the larger framework of a
treatment program that provides pharmacotherapy, family work (when
a family is available), and multiple levels of support, both material
and psychological. The approach is carefully tailored to the patient's
phase of recovery from an acute episode and the patient's
residual level of severity, disability, and vulnerability to relapse.
During the stable phase, negative symptoms (e.g., affective
flattening, alogia, avolition) may be primary and represent a core
feature of schizophrenia, or they may be secondary to psychotic symptoms,
a depressive syndrome, medication side effects (e.g., dysphoria),
or environmental deprivation. The effectiveness of psychosocial
treatments for reducing negative symptoms is not well studied. Furthermore,
most research (for both psychosocial and pharmacological treatments)
does not distinguish between primary and secondary negative symptoms.
Thus, the generic term "negative symptoms" is
used to summarize these findings. Some studies of cognitive behavior
therapy report improvements in residual negative symptoms. In a
review of three studies, Rector and Beck (188) reported a large
aggregated effect size favoring cognitive behavior therapy over
supportive therapy for reducing negative symptoms. Also, one study
of family psychoeducation reported an improvement in negative symptoms
with this intervention (189).
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c) Improving functional status and quality of life
A primary treatment goal during the stable phase is to enable
the patient to continue the recovery process and to achieve the
goals of improved functioning and quality of life. To the degree
to which active positive symptoms impair functional capacity, medications
that reduce positive symptoms may improve functioning. However,
research indicates consistently that positive symptoms show a low correspondence
with functional impairments among patients with schizophrenia (190).
Rather, it is the negative symptoms and cognitive impairments that
are more predictive of functional impairment (191). Because available
medications have at best only modest effects on these illness dimensions,
it is not surprising that there is scant evidence that medications
improve functional status beyond that achieved through reduction
of impairing positive symptoms. Consequently, certain psychosocial
and rehabilitative interventions are essential to consider in the
stable phase to enhance functional status.
Supported employment is an approach to improve vocational
functioning among persons with various types of disabilities, including
schizophrenia (192). The evidence-based supported employment programs
that have been found effective include the key elements of individualized
job development, rapid placement emphasizing competitive employment,
ongoing job supports, and integration of vocational and mental health
services. Randomized trials have consistently demonstrated the effectiveness
of supported employment in helping persons with schizophrenia
to achieve competitive employment (193, 194). Employment outcomes
related to the duration of employment and to the amount of earnings
also favor supported employment over traditional vocational services.
Further, there is no evidence that engagement in supported employment
leads to stress, increased symptoms, or other negative outcome (159).
Evidence is inconsistent about the relationship between clinical
and demographic variables and successful vocational performance;
therefore, it is recommended that any person with schizophrenia who
expresses an interest in work should be offered supported employment.
Promoting job retention is a continuing challenge even for supported
employment. Studies have found that persons with schizophrenia experience
considerable difficulties retaining jobs achieved through supported
employment (162, 194). This problem appears to be related to neurocognitive
impairments (195), among other factors.
Social skills training has been found helpful in addressing
functional impairments in social skills or activities of daily living.
The key elements of this intervention include behaviorally based instruction,
modeling, corrective feedback, and contingent social reinforcement.
Clinic-based skills training should be supplemented with practice
and training in the patient's day-to-day environment. The
results of controlled trials indicate the benefit of skills training
in improving illness knowledge, social skills, and symptom and medication
management when offered with adequate pharmacotherapy (167). Evidence
is strongest for the benefit of skills training in increasing the
acquisition of skills assessed by situationally specific measures.
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d) Patient and self-help treatment organizations
Peer support is social-emotional and sometimes instrumental
support that is mutually offered or provided by persons having a
mental health condition, i.e., mental health consumers, to others
sharing a similar mental health condition to bring about a desired
social or personal change (196). The oldest and most widely available
type of peer support is self-help groups. Based largely on uncontrolled
studies of self-help groups for persons with severe mental illness,
Davidson et al. (197) concluded that self-help groups seem to improve
symptoms and increase participants' social networks and
quality of life. Additional studies of self-help groups have demonstrated
other positive outcomes, including reductions in hospitalizations,
improved coping, greater acceptance of the illness, improved medication
adherence and illness management, improved daily functioning, lower levels
of worry, and higher satisfaction with health (198–200,
unpublished 1989 manuscript of M. Kennedy).
Within the realm of consumer-provided or -delivered services
are consumer-run or -operated services, consumer partnership
services, and consumer employees. Consumer-run or -operated services
are services that are planned, operated, administered, and evaluated
by consumers (201, 202). Those service programs that are not freestanding
legal entities but share control of the operation of the program
with nonconsumers are categorized as consumer partnerships. Consumer
employees are persons who fill positions designated for consumers
as well as consumers who are hired into traditional mental health
positions. Reviews of peer support/consumer-provided services
specifically for persons with severe mental illness have generated
positive results, but the findings are somewhat tentative, given
the infancy of the research area (197, 203, 204). Such services
have been associated with reduced hospitalizations, reduced use
of crisis services, improved social functioning, reduced substance
use, and improved quality of life (205–209).
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3. Use of antipsychotic medications in the stable
phase
Once a patient reaches the stable or maintenance phase of
treatment, it is important for the physician to develop a long-term
treatment management plan that minimizes the risk of relapse, monitors
for and minimizes the severity of side effects, and to the extent
possible addresses residual symptoms.
Antipsychotics can reduce the risk of relapse in the stable
phase of illness to less than 30% per year (210–215).
Without maintenance treatment, 60%–70% of
patients relapse within 1 year, and almost 90% relapse
within 2 years. Strategies can be used to increase the likelihood
that patients will adhere to prescribed medication regimens. Such
strategies are described in Section II.A.3, "Developing a Therapeutic Alliance and Promoting Treatment Adherence".
Deciding on the dose of an antipsychotic medication during
the stable phase is complicated by the fact that there is no reliable
strategy available to identify the minimum effective dose to prevent relapse.
Although higher doses are often more effective at reducing relapse
risk than lower doses, higher doses often cause greater side effects
and lessen subjective tolerability; therefore, clinicians should
attempt to treat at a dose that minimizes side effects but is still
in the effective range of a particular drug (refer to Table 2).
For most patients treated with first-generation antipsychotics, clinicians
should use a dose around the "EPS threshold" (94),
since studies indicate that higher doses are usually not more efficacious
and increase risk of subjectively intolerable side effects (95–97).
Lower doses of first-generation antipsychotic medications may be
associated with improved adherence and better subjective state and
perhaps ultimately better functioning. Second-generation antipsychotics
can generally be administered at doses that are therapeutic but
will not induce extrapyramidal side effects. The advantages of decreasing
antipsychotics to the "minimal effective dose" should
be weighed against a somewhat greater risk of relapse and more frequent
exacerbations of schizophrenic symptoms (216). Recent evidence suggests
potentially greater efficacy in relapse prevention for the second-generation
antipsychotic drugs (215, 217); however, whether this result is
due to better efficacy or some other factor such as greater treatment adherence
or reduced side effects is unclear.
The available antipsychotics are associated with differential
risk of a variety of adverse effects, including neurological, metabolic,
sexual, endocrine, sedative, and cardiovascular effects (Table 4). A
suggested approach to monitoring of side effects is detailed in Table 1 and should be based on the side effect profile of the prescribed
antipsychotic as detailed in Part B, Section V.A.1, "Antipsychotic Medications."
Antipsychotic treatment often results in substantial improvement
or even remission of positive symptoms. However, most patients remain
functionally impaired because of negative symptoms, cognitive deficits,
and impaired social function. It is important to evaluate whether
residual negative symptoms are in fact secondary to a parkinsonian
syndrome or an untreated major depressive syndrome, since interventions
are available to address these negative symptoms. There are few proven
treatment options for residual positive symptoms, primary negative
symptoms, cognitive deficits, or social impairments (see Section
II.E, "Special Issues in Caring for Patients With Treatment-Resistant
Illness").
Most patients who develop schizophrenia and related psychotic
disorders (schizoaffective disorder and schizophreniform disorder)
are at very high risk of relapse in the absence of antipsychotic treatment.
Emerging evidence suggests this may even be true for first-episode
patients; some studies (46, 218) have shown that more than 80% of
such patients who do not receive antipsychotic treatment experience
some recurrence of symptoms in the 5 years after remission. Unfortunately,
there is no reliable indicator to differentiate the minority who
will not relapse from the majority who will relapse. Antipsychotics
are highly effective in the prevention of relapse in remitted first-episode
patients. One-year relapse risk varies from 0% to 46% of
patients who are prescribed antipsychotics (210–213). Adherence
to maintenance antipsychotic medication likely has an influence
on effectiveness and may contribute to varying relapse rates. The
most prudent treatment options that clinicians may discuss with
remitted first- or multi-episode patients include either 1) indefinite
antipsychotic maintenance medication or 2) medication discontinuation
(after at least 1 year of symptom remission or optimal response
while taking medication) with close follow-up and with a plan to
reinstitute antipsychotic treatment on symptom recurrence. However,
evidence indicates that sustained treatment is associated with fewer
relapses than is targeted intermittent treatment (219). In addition,
intermittent treatment strategies appear to increase rather than
decrease the risk of tardive dyskinesia. Clinicians should engage
patients in a discussion of the long-term potential risks of maintenance
treatment with the prescribed antipsychotic (see Part B, Section
V.A.1, "Antipsychotic Medications") versus the
risks of relapse (e.g., the effect of relapse on social and vocational functioning,
the risk of dangerous behaviors with relapse, and the risk of developing
chronic treatment-resistant symptoms). If a decision is made to
discontinue antipsychotic medication, the discontinuation should
be gradual (e.g., reducing the dose by 10% per month).
Additional precautions should be taken to minimize the risk of a
psychotic relapse. The physician should educate the patient and
the family about early signs of relapse, advise them to develop
plans for action should these signs appear, and suggest that the
patient continue to be seen by a physician on a regular basis.
Indefinite maintenance antipsychotic medication is recommended
for patients who have had multiple prior episodes or two episodes
within 5 years. Patients taking antipsychotic medication should
also be monitored for signs and symptoms of impending or actual
relapse, since even in adherent patients the risk of relapse in
chronic schizophrenia is about 30% per year. The treatment program
should be organized to respond quickly when a patient, family member,
or friend reports any symptoms that could indicate an impending
or actual relapse. Early intervention using supportive therapeutic
techniques and increasing medication as indicated can be very helpful
in reducing the likelihood of relapse and hospitalization (220).
During prodromal episodes, patients and family members should be
seen more frequently for treatment, monitoring, and support, and
assertive outreach, including home visits, should be used when indicated.
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4. Use of adjunctive medications in the stable phase
Other psychoactive medications are commonly added to antipsychotic
medications in the stable phase to treat comorbid conditions, aggression,
anxiety, or other mood symptoms; to augment the antipsychotic effects
of the primary drug; and to treat side effects. Other medications
that may address treatment-resistant and residual psychotic symptoms
are discussed in Section II.E, "Special Issues in
Caring for Patients With Treatment-Resistant Illness".
Adjunctive medications are commonly prescribed for comorbid
conditions. For example, major depression and obsessive-compulsive
disorder are common comorbid conditions in patients with schizophrenia
and may respond to antidepressant medications (221–223).
However, some antidepressants (those that inhibit catecholamine
reuptake) can potentially sustain or exacerbate psychotic symptoms
in some patients (103). Benzodiazepines may be helpful for managing
anxiety during the stable phase of treatment (224), although risk
of dependence and abuse exists with chronic use of this class of
medication. There is some evidence that mood stabilizers and beta-blockers (100–102) may
be effective in reducing the severity of recurrent hostility and
aggression. Mood stabilizers may also address prominent mood lability.
As mentioned previously, attention must be given to potential drug
interactions, especially related to metabolism by the cytochrome
P450 enzymes (48, 49).
Patients treated with first-generation antipsychotics may
require the long-term use of medications for treatment of extrapyramidal
side effects (Table 5). Although the study findings are not consistent, there
is some evidence that vitamin E may reduce the risk of development
of tardive dyskinesia (225, 226). Given the low risk of side effects
associated with vitamin E, patients may be advised to take 400–800
I.U. daily as prophylaxis.
Many other medications may be used to treat or reduce the
risk of various antipsychotic side effects. These medications
are discussed with each specific antipsychotic in Part B, Section
V.A.1, "Antipsychotic Medications."
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5. Use of ECT in the stable phase
Clinical observations (227, 228) and a single randomized clinical
trial (229) suggest that maintenance ECT may be helpful for some
patients who have responded to acute treatment with ECT but for
whom pharmacological prophylaxis alone has been ineffective or cannot be
tolerated. The frequency of treatments varies from patient to patient
and depends on the degree of clinical response and side effects
of treatment (107). As with acute treatment with ECT, available
evidence suggests that treatment with antipsychotics should continue
during the maintenance ECT course (229).
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E. Special Issues in Caring for Patients With
Treatment-Resistant Illness
About 10%–30% of patients have
little or no response to antipsychotic medications, and up to an additional
30% of patients have partial responses to treatment, meaning
that they exhibit improvement in psychopathology but continue to
have mild to severe residual hallucinations or delusions. Even if
a patient's positive symptoms respond or remit with antipsychotic
treatment, other residual symptoms, including negative symptoms
and cognitive impairment, often persist. Treatment resistance is
defined as little or no symptomatic response to multiple (at least
two) antipsychotic trials of an adequate duration (at least 6 weeks)
and dose (therapeutic range).
Treatment may be completely or partially unsuccessful for
a variety of reasons. The patient may receive a suboptimal dose
of antipsychotic, either because an inadequate dose has been prescribed or
because the patient does not take some or all of the prescribed
antipsychotic. The prescribed antipsychotic may be partially or
fully ineffective in treating acute symptoms or in preventing relapse. Substance
use may also cause or contribute to treatment resistance.
In assessing treatment resistance, clinicians should carefully
evaluate whether the patient has had an adequate trial of an antipsychotic,
including whether the dose is adequate and whether the patient has
been taking the medication as prescribed. Strategies for improving adherence
are described in Section II.A.3, "Developing a Therapeutic Alliance and Promoting Treatment Adherence".
Even when patients are taking antipsychotics, suboptimal treatment
response and residual symptoms are common. There are considerable
differences between patients in responsiveness to available antipsychotics.
However, currently there is no reliable strategy to predict response
or risk of side effects with one agent compared with another. Thus,
adequate trials of multiple antipsychotics are often needed before
antipsychotic treatment is optimized. Complicating the evaluation
of treatment response is the fact that there is some time delay
between initiation of treatment and full clinical response. An initial
trial of 2–4 weeks generally is needed to determine if
the patient will have any symptomatic response, and symptoms can
continue to improve for up to 6 months (230, 231).
Because of clozapine's superior efficacy, a trial
of clozapine should be considered for a patient with a clinically
inadequate response to antipsychotic treatment or for a patient
with suicidal ideation or behavior (55). Besides clozapine, there
are limited options for the many patients who have severe and significant residual
symptoms even after antipsychotic monotherapy has been optimized,
and none have proven benefits. Various augmentation strategies that
have limited or no evidence supporting their efficacy are often
used. However, clinicians may consider a time-limited trial of an
agent to determine if it offers any benefit to an individual patient.
To avoid risking side effects and potential drug interactions, it
is important that the actual efficacy of adjunctive medications
is carefully evaluated and that adjunctive medications that do not
produce clinical benefits are discontinued. Depending on the type of
residual symptom (e.g., positive, negative, cognitive, or mood symptoms;
aggressive behavior), augmentation strategies include adding another
antipsychotic (232–234), anticonvulsants (102, 235–237),
benzodiazepines (224), N-methyl-d-aspartate
(NMDA) receptor allosteric agonists (e.g., d-serine [238],
glycine [239–242], d-cycloserine [243–246]),
and cholinergic agonists (247–249). ECT has demonstrated
benefits in patients with treatment-resistant symptoms (106–108).
Cognitive behavior therapy techniques may have value in improving
positive symptoms with low risk of side effects (98). In addition,
cognitive remediation is under investigation as a therapeutic strategy
to reduce the severity of cognitive deficits (250).
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F. Clinical Features Influencing the Treatment Plan
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1. Psychiatric features
Active psychosis is dangerous to a person's safety;
disrupts capacity to function, life, and reputation; and if persistent
for too long can negatively affect prognosis (251). In contrast,
early treatment may result in a significant reduction in morbidity
and better quality of life for patients and families (252–256).
Approximately 25 studies have examined this phenomenon; about two-thirds
have shown a significant association between earlier treatment and better
outcome on one or more measures, and none has shown a significant
association between delayed treatment and better outcome
on any measure (257). Despite the benefits of early treatment, there
is usually a delay of 1–2 years between the onset of psychotic
symptoms and the time the patient first receives adequate psychiatric
treatment (252, 258–261). Thus, once psychosis is evident,
it should be treated immediately.
In some persons, particularly those with a family history
of schizophrenia or other factors influencing risk, prodromal symptoms
may be apparent before the development of a full schizophrenia syndrome.
Although empirical evidence on long-term outcome is limited, antipsychotic
medication treatment may also be helpful in some persons with prodromal
symptoms (262–264).
When a patient presents with a first episode of psychosis,
close observation and documentation of the signs and symptoms over
time are important because initial psychotic episodes can be polymorphic
and evolve into a variety of specific disorders (e.g., schizophreniform
disorder, bipolar disorder, schizoaffective disorder). There is
controversy over whether first-episode patients should be treated
as outpatients or in the hospital. Inpatient care offers both risks
and protections. On the one hand, the experience of a first psychiatric
hospitalization, especially in a closed setting with many chronically
ill patients, can be frightening and produce its own trauma (265).
On the other hand, the nature and severity of a first episode are
often unknown, unpredictable, and require more than "usual" surveillance.
A hospital setting also allows for careful monitoring of the psychotic
symptoms as well as any side effects, including acute dystonia,
akathisia, or neuroleptic malignant syndrome (266), that may arise
from treatment with antipsychotic medications.
Patients with first-episode psychosis are comparatively more
treatment responsive than patients with multiple episodes of psychosis
but, at the same time, are quite sensitive to side effects (267–270).
Up to the early 1990s, drug treatment for a first episode of psychosis
was limited to first-generation antipsychotic medications that could
cause severe sedation and extrapyramidal side effects. The second-generation
antipsychotic medications have less propensity to cause extrapyramidal
side effects, and patients are hence less likely to need concomitant
anticholinergic agents (271–273).
More than 70% of first-episode patients achieve a
full remission of psychotic signs and symptoms within 3–4
months, with 83% achieving stable remission at the end
of 1 year (274). Studies also reveal that first-episode patients
often respond to low doses of antipsychotic medications (275–279).
However, predictors of poor treatment response include male gender,
pre- or perinatal injury, more severe hallucinations and delusions,
attentional impairments, poor premorbid function, longer duration
of untreated psychosis (280), the development of extrapyramidal
side effects (281), and high levels of expressed emotion in the
patient's family (282–289).
Not uncommonly, symptoms of schizophrenia have their onset
before adulthood, and aspects of treatment may differ in children
and adolescents. For more information on treating children and adolescents,
readers are referred to the American Academy of Child and Adolescent
Psychiatry's Practice Parameter for the
Assessment and Treatment of Children and Adolescents With Schizophrenia (290).
Once remission of psychotic symptoms is achieved, a high priority
should be placed on minimizing risk of relapse, given its potential
clinical, social, and vocational costs. In particular, recurrent episodes
are associated with increasing risk of chronic residual symptoms
and evidence of anatomical neuroprogression (257, 280, 291–293).
Patients, their families, and treating clinicians often hope that
symptom remission indicates that the disease will not become chronic,
although this is true only for a minority (about 10%–20%)
of patients (46, 218, 294). Thus, clinicians should candidly discuss
the high risk of relapse and factors that may minimize relapse risk.
Although there is very little study of factors that act to maintain
recovery in remitted first-episode patients, evidence suggests that
antipsychotics are highly effective in prevention of relapse. In
patients for whom antipsychotics are prescribed, 1-year relapse
risk varies from 0% to 46%, with relapse rates
of patients who discontinue taking medication being up to five times
higher than rates for those who continue treatment (46, 210–213).
Since adherence to maintenance medication treatment likely influences
effectiveness, it may contribute to the varying relapse rates found
in these studies.
In arriving at a plan of treatment with remitted first-episode
patients, clinicians should engage patients in discussion of the
long-term potential risks of maintenance treatment with the prescribed antipsychotic
versus risks of relapse (e.g., effect of relapse on social and vocational
function, risk of dangerous behaviors with relapse, and risk of
developing chronic treatment-resistant symptoms). Prudent treatment
options that clinicians may discuss with remitted patients include
either 1) indefinite antipsychotic maintenance medication (295) or
2) medication discontinuation with close follow-up and a plan of
antipsychotic reinstitution with symptom recurrence. Medications
should never be stopped abruptly, as rebound psychosis
may result and may be misinterpreted as a reoccurrence.
In addition to maintenance antipsychotic medication, other potential
strategies to maintain recovery in remitted first-episode patients
include enhancing stress management and eliminating exposure to
cannabinoids and psychostimulants (296).
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b) Subtypes and deficit symptoms
According to DSM-IV-TR, the classic subtypes of schizophrenia
are paranoid, disorganized, catatonic, undifferentiated, and residual.
There are at present no treatment strategies specific to the various
subtypes, with the exception of the use of benzodiazepines for catatonia.
The deficit/nondeficit categorization, or the deficit syndrome,
is also important to recognize, although there are also no specific
treatments (297). The negative symptoms of schizophrenia may be
classified as primary or secondary. Negative symptoms may be primary
and represent a core feature of schizophrenia, or they may be secondary to
positive psychotic symptoms (e.g., paranoid withdrawal), medication
side effects (e.g., dysphoria), depressive symptoms (e.g., anhedonia),
anxiety symptoms (e.g., social phobia), demoralization, or environmental
deprivation (e.g., in chronic institutionalization). Deficit schizophrenia
is heavily loaded with enduring primary negative symptoms such as
affective flattening, alogia, and avolition.
The prevalence of deficit states in first-episode schizophrenia
has been estimated to be between 4% and 10% (298).
Negative symptoms are already present in the prodromal phase (299–301),
and the prevalence increases with the length of the schizophrenic
illness (302–306). Male patients have been found to experience
more negative symptoms than female patients (307–309).
Patients with deficit schizophrenia are also found to have poorer
premorbid adjustment during childhood and early adolescence. They
exhibit more impairment in general cognitive abilities and have
problems in sequencing of complex motor acts, which suggests frontoparietal
dysfunction (310).
Treatment of negative symptoms begins with assessing the patient
for factors that can cause the appearance of secondary negative
symptoms (311). The treatment of such secondary negative symptoms
consists of treating their cause, e.g., antipsychotics for primary
positive symptoms, antidepressants for depression, anxiolytics for
anxiety disorders, or antiparkinsonian agents or antipsychotic dose
reduction for extrapyramidal side effects. If negative symptoms
persist after such treatment, they are presumed to be primary negative symptoms
of the deficit state (312).
There are no treatments with proven efficacy for primary negative
symptoms. Clozapine was reported to be effective for negative symptoms
in earlier short-term trials (313), but subsequent longer-term studies
challenged such claims (314, 315), although clozapine treatment
was associated with significant improvement in social and occupational
functioning (314). The second-generation antipsychotic medications
have been reported to be useful against negative symptoms (316–322),
but this improvement may be accounted for by their having less propensity
to cause extrapyramidal side effects (323).
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c) Substance use disorders
More than one-third of patients with schizophrenia spectrum
disorders also have a substance use disorder, and people with schizophrenia
show six times the risk of developing a substance use disorder than
do persons in the general population (324). Other research finds
that between 20% and 65% of people with schizophrenia
experience comorbid substance use disorders (325–328).
A recent Australian study found the 6-month and lifetime prevalence
of substance abuse or dependence among people with schizophrenia
to be 26.8% and 59.8%, respectively (329).
Substance abuse in schizophrenia has been associated with
male gender, single marital status, less education, earlier age
at onset of schizophrenia and at first hospital admission, frequent
and longer periods of hospitalization, more pronounced psychotic
symptoms, more severe cerebral gray matter volume deficits, and
negative consequences such as poor treatment adherence,
depressive symptoms, suicide, violence, legal problems, incarceration,
severe financial problems, family burden, housing instability, and
increased risk of HIV infection (327, 330–332) and hepatitis
infection, particularly hepatitis C infection (333). Substance abuse
has been associated with precipitation of schizophrenia at an earlier
age (334–340), and in some studies amphetamine abuse has
been associated with an earlier age of onset (341). Alcohol and
a variety of other substances have also been associated with symptom
relapses in schizophrenia (342). Nicotine, alcohol, cannabis,
and cocaine have been found to be the most commonly abused substances.
Patients may also abuse prescribed medications such as benzodiazepines
and antiparkinsonian agents.
The goals of treatment for patients with schizophrenia who
also have a substance use disorder are the same as those for treatment
of schizophrenia without comorbidity but with the addition of the goals
for treatment of substance use disorders, e.g., harm reduction,
abstinence, relapse prevention, and rehabilitation (343).
Evaluation of the patient with schizophrenia should always
include a comprehensive inquiry into possible substance use. Self-report
is often unreliable; corroborating evidence from all sources such as
family members, friends, community-based case managers, and treatment
personnel should be sought (330, 344). Screening instruments for
substance use disorders developed for the general population, such
as the Alcohol Use Disorders Identification Test (AUDIT) (345),
can be used, but screening instruments specifically for patients
with severe mental illnesses, such as the Dartmouth Assessment of
Lifestyle Instrument (346), have been developed and may have greater
sensitivity for detecting substance use disorders in people with
schizophrenia. Laboratory investigations such as urine and blood
toxicology for abused substances and liver function tests should
be carried out. Many patients with schizophrenia do not develop
the full physiological dependence syndrome associated with dependence
on alcohol or other substances (330). However, even use of low levels
of alcohol or other substances by patients with schizophrenia can
have untoward consequences. Psychiatrists should therefore attend
carefully to the presence of alcohol or other substance use and
be familiar with the potential negative consequences described earlier.
The rates of current substance use will likely be higher in acute
settings such as the emergency department, and thus the index of
suspicion and effort devoted to assessment of substance use should be
especially high in such settings.
Traditionally, patients with schizophrenia and comorbid substance
use disorders were treated in separate programs, either sequentially
or in parallel, for the two types of disorder. Since the mid-1980s,
a comprehensive integrated treatment model has been adopted to provide
continuous outpatient treatment interventions and support over long
periods of time (months to years), enabling patients to acquire
the skills they need to manage both illnesses and to pursue functional
goals. In this model, the same clinicians or teams of clinicians
provide treatment both for substance use disorders and for other
mental disorders. This form of treatment features assertive outreach,
case management, family interventions, housing, rehabilitation,
and pharmacotherapy. It also includes a stage-wise motivational
approach for patients who do not recognize the need for treatment
of substance use disorders and behavioral interventions for those
who are trying to attain or maintain abstinence. The interventions
have been associated with reduced substance use and attainment of remission (347–350).
Initially, many patients need interventions to build motivation
rather than to achieve abstinence. Special efforts are
made to help them recognize that their substance
use is interfering with their ability to pursue personal
goals and to nurture their desire to reduce and eliminate their
substance use (161, 349). Such efforts represent examples of interventions
during the second (persuasion) stage in a four-stage dual-diagnosis
treatment model based on readiness for change; the other treatment
stages are engagement, active treatment, and relapse prevention (351).
Studies show that treatment programs with these characteristics
can be effective in reducing substance use and in decreasing the
frequency and severity of psychotic decompensations (332,
352–354). Collaboration with family members is often helpful
for both the patients and the family members (64, 171,
355, 356).
In practice, treatment of substance use disorders is commonly
conducted by means of a group therapy approach, usually after patients
have achieved stabilization of their schizophrenic symptoms. The
therapeutic approach should be an integrated one that takes into
account patients' cognitive deficits and limited tolerance
for stress. Generally, groups should emphasize support, psychoeducation,
and skills training (344, 352, 357). The length and frequency of
group sessions should be regulated according to the attention span and
interactive tolerance of the patients. Therapists should be active
in keeping the group structured and focused and should limit the
amount of stress by avoiding the direct confrontation of patients that
is common to traditional treatment programs for persons with substance
use disorders. Patients should understand that they have two complex
chronic disorders that together lead to a poorer prognosis than
each would have separately. Patients who have not yet attained complete
abstinence should be accepted into treatment, with abstinence as
a treatment goal (344, 352, 358). Patients who do not view abstinence
as a treatment goal may still be successfully engaged in treatment
that is aimed at achieving abstinence (359). Community-based self-help
and support groups such as Alcoholics Anonymous or Narcotics Anonymous
can be important in the recove