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  • Goals of treatment

    • Ensure that symptom remission or control is sustained.

    • Maintain or improve the patient's level of functioning and quality of life.

    • Effectively treat increases in symptoms or relapses.

    • Continue to monitor for adverse treatment effects.

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1. Assessment in the Stable Phase

  • Ongoing monitoring and assessment are necessary to determine whether the patient might benefit from alterations in the treatment program.

  • Perform a clinical assessment for extrapyramidal symptoms (for patients taking antipsychotic medications) at each clinical visit.

  • Perform a clinical assessment for abnormal involuntary movements every 6 months for patients taking first-generation antipsychotics and every 12 months for patients taking second-generation antipsychotics. For patients at increased risk (e.g., elderly patients), assessments should be made every 3 months and 6 months with treatment using first-generation and second-generation antipsychotics, respectively.

  • Monitor the patient's weight and BMI at each visit for 6 months and quarterly thereafter. For patients with BMI in the overweight (25 to 29.9 kg/m2) or obese (30 kg/m2) range, routinely monitor for obesity-related health problems (e.g., blood pressure, serum lipids, clinical symptoms of diabetes).

  • Monitor fasting blood glucose or hemoglobin A1c at 4 months and then annually, and monitor other blood chemistries (e.g., electrolytes; renal, liver, and thyroid function) annually or as clinically indicated; consider drug toxicology screen if clinically indicated.

  • Depending on the specific medication being prescribed, consider other assessments, including vital signs, CBC, ECG, screening for symptoms of hyperprolactinemia, and ocular examination.

  • If the patient agrees, maintain strong ties with individuals who are likely to notice any resurgence of symptoms and the occurrence of life stresses and events.

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2. Psychosocial Treatments in the Stable Phase

  • Select appropriate psychosocial treatments based on the circumstances of the individual patient's needs and social context.

  • Psychosocial treatments with demonstrated efficacy include

    • family interventions,

    • supported employment,

    • assertive community treatment,

    • social skills training, and

    • cognitive behaviorally oriented psychotherapy.

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3. Use of Antipsychotic Medications in the Stable Phase

  • Antipsychotics can reduce the risk of relapse in the stable phase of illness to less than 30% per year.

  • For most patients treated with first-generation antipsychotics, clinicians should prescribe a dose close to the "EPS threshold" (i.e., the dose that will induce extrapyramidal side effects with minimal rigidity detectable on physical examination).

  • Second-generation antipsychotics can generally be administered at doses that are therapeutic but that will not induce extrapyramidal side effects.

  • Weigh advantages of decreasing antipsychotics to the "minimal effective dose" against a somewhat greater risk of relapse and more frequent exacerbations of schizophrenia symptoms.

  • Evaluate whether residual negative symptoms are in fact secondary to a parkinsonian syndrome or an untreated major depressive syndrome, and treat accordingly.

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4. Use of Adjunctive Medications in the Stable Phase

  • Add other psychoactive medication 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.

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5. Use of ECT in the Stable Phase

  • Maintenance ECT may be helpful for some patients who have responded to acute treatment with ECT but for whom pharmacologic prophylaxis alone has been ineffective or cannot be tolerated.

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6. Encourage the Patient and Family to Use Self-Help Treatment Organizations

References

NOTE:
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