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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
Continue to monitor for adverse treatment
Ongoing monitoring and assessment are necessary to determine
whether the patient might benefit from alterations in the treatment
Perform a clinical assessment for extrapyramidal symptoms
(for patients taking antipsychotic medications) at each clinical
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.
Select appropriate psychosocial
treatments based on the circumstances of the individual patient's needs
and social context.
Psychosocial treatments with demonstrated
assertive community treatment,
social skills training, and
cognitive behaviorally oriented psychotherapy.
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
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.
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.
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.