APA's Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition, was published in April 2004 (1). This watch highlights key research studies published since that date. The studies were identified by a MEDLINE literature search for meta-analyses and randomized, controlled trials published between 2002 and 2008, using the same key words used for the literature search performed for the 2004 guideline.

With regard to pharmacotherapy, there have been several important randomized trials of antipsychotics. For chronic schizophrenia, trials include the National Institute of Mental Health (NIMH) Clinical Antipsychotic Trial for Intervention Effectiveness (CATIE) and the United Kingdom–funded Cost Utility of the Latest Antipsychotics in Schizophrenia (CUtLASS). For first-episode schizophrenia, there are two industry-funded trials, the European First Episode Schizophrenia Trial (EUFEST)—funded by AstraZeneca, Pfizer, and Sanofi-Aventis—and the Comparison of Atypicals for First Episode Schizophrenia (CAFE)—funded by AstraZeneca. For early-onset schizophrenia, there is one trial, the NIMH-funded Treatment of Early-Onset Schizophrenia Spectrum Disorders (TEOSS). These trials point to a reconsideration of treatment with the antipsychotics perphenazine and molindone and by extension other first-generation antipsychotics, with the possible exception of haloperidol, for which some trials have shown greater rates of extrapyramidal side effects or less favorable clinical response (2). In addition, a recent population-based cohort study (3) that encompassed 11 years of follow-up showed decreased rates of mortality with perphenazine as compared with other first- and second-generation antipsychotic agents; only clozapine use was associated with lower rates of overall mortality.

In addition, randomized controlled trials have demonstrated the safety and efficacy of a new antipsychotic, paliperidone, leading to its approval by the U.S. Food and Drug Administration (FDA). Several controlled clinical trials have investigated treatments to prevent or treat antipsychotic-related weight gain and metabolic changes. Additionally, there have been promising clinical trials of bupropion and behavioral interventions to reduce smoking in schizophrenia patients.

With regard to psychosocial treatments, new studies lend some additional support to the treatments recommended in the 2004 guideline. In addition, combinations of treatments have begun to be tested to enhance supported employment and social skills training. An evidence base has developed for interventions for obesity and for smoking cessation. There also has been continued study of cognitive remediation and peer support and peer-delivered services, which have the potential to play a useful role in recovery.

For the period April 2008 to August 2009, Dr. Dixon reports attending a consultation meeting for Janssen and receiving a grant from Bristol-Meyers-Squibb for investigator-initiated research, Dr. Perkins reports receiving research funding from Janssen (ended January 2009) and reports receiving income for consulting for Dainippon (data safety monitoring board on lurasidone studies) and for serving on speakers bureaus for Eli Lilly, and Dr. Calmes reports no competing interests. The Executive Committee on Practice Guidelines reviewed this watch and found no evidence of influence from these relationships.

The American Psychiatric Association's (APA's) practice guidelines are developed by expert work groups using an explicit methodology that includes rigorous review of available evidence, broad peer review of iterative drafts, and formal approval by the APA Assembly and Board of Trustees. APA practice guidelines are intended to assist psychiatrists in clinical decision making. They are not intended to be a standard of care.

The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by the psychiatrist in light of the clinical data presented by the patient and the diagnostic and treatment options available. Guideline watches summarize significant developments in practice since publication of an APA practice guideline. Watches may be authored and reviewed by experts associated with the original guideline development effort and are approved for publication by APA's Executive Committee on Practice Guidelines. Thus, watches represent opinion of the authors and approval of the Executive Committee but not policy of the APA. This guideline watch was published in September 2009. Copyright © 2009. American Psychiatric Association. All rights reserved.


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