Performance in Practice: Practice Assessment Tool for the Care of Patients With Schizophrenia
Abstract
Schizophrenia is associated with significant health, social, occupational, and economic burdens, including increased mortality. Despite extensive and robust research on the treatment of individuals with schizophrenia, many individuals with the illness do not currently receive evidence-based pharmacological and nonpharmacological treatments. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia, Third Edition, aims to enhance knowledge and increase the appropriate use of interventions for schizophrenia, thereby improving the quality of care and treatment outcomes. To this end, this evidence-based Performance in Practice tool can facilitate the implementation of a systematic approach to practice improvement for the care of individuals with schizophrenia. This practice assessment activity can also be used in partial fulfillment of Continuing Medical Education and Maintenance of Certification, part IV, requirements, which can also satisfy requirements for the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System program.
Schizophrenia is associated with significant health, social, occupational, and economic burdens as a result of its early onset and its severe and often persistent symptoms (Box 1) (1–4). For example, unemployment, homelessness, and incarceration are more likely among individuals with schizophrenia than among individuals without a psychiatric disorder (4–7). In addition, schizophrenia is associated with a very high global burden of disease, making it one of the top 20 causes of disability worldwide (8).
BOX 1. DSM-5 criteria for schizophreniaa
A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g. frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e. diminished emotional expression or avolition).
B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).
C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e. active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g. odd beliefs, unusual perceptual experiences).
D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.
E. The disturbance is not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition.
F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated).
a Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington, DC, American Psychiatric Association, 2013. Copyright © 2013 American Psychiatric Association. Used with permission.
Individuals with schizophrenia also have a shortened life span and standardized mortality ratios that are reported to be twofold to fourfold those of the general population (9–17). About 4%−10% of persons with schizophrenia die by suicide (10, 12, 16, 18–20). Other contributors to death are co-occurring psychiatric disorders (21), including substance use disorders (22); accidents and traumatic injuries; and physical conditions, such as malignancies and cardiovascular, respiratory, and infectious diseases (1, 9–17). These increases in morbidity and mortality are likely associated with factors such as obesity, diabetes, hyperlipidemia, greater use of cigarettes, reduced engagement in health maintenance (e.g., diet, exercise), lack of access to psychiatric treatment, and disparities in access to preventive health care and treatment for physical conditions among individuals with schizophrenia (23–32).
Optimizing the care of individuals with schizophrenia is essential to reducing the considerable economic and human costs of this disorder. In addition, performance in practice approaches may be able to reduce gaps in care. For example, studies have suggested that a significant proportion of individuals with treatment-resistant schizophrenia do not receive treatment with clozapine, despite the evidence for its effectiveness (33–39). Similarly, long-acting injectable formulations of antipsychotic medications are often underused but can provide many benefits for patients and families (40–43). Even among those receiving pharmacologic treatments, appropriate and timely monitoring for benefits and side effects of treatment are less than optimal (44). Co-occurring psychiatric disorders, including nicotine dependence and other substance use disorders, are often unrecognized or unaddressed (22, 45–57). Evidence also suggests low rates of guideline-concordant monitoring for metabolic risk factors, including hyperlipidemia, diabetes, and obesity (58, 59), which is of particular concern given the association between metabolic risk factors and poor health outcomes (see Table 1). Psychosocial interventions for schizophrenia have not typically been part of behavioral health quality measures (60, 61), yet national data (62) and anecdotal observations (63) also suggest significant underuse of these interventions. These gaps in care are troubling because evidence-based psychosocial and psychopharmacologic interventions can reduce symptoms and improve functioning among individuals with schizophrenia.
| Assessment | Initial or baseline | Follow-up |
|---|---|---|
| Monitoring physical status or detecting concomitant physical conditions | ||
| Vital signs | Pulse, blood pressure | Pulse, blood pressure, temperature as clinically indicated |
| Body weight and height | Body weight, height, and BMI | BMI every visit for six months and at least quarterly thereafter |
| Hematology | CBC, including ANCb | CBC, including ANC if clinically indicated (e.g., patients treated with clozapine) |
| Blood chemistries | Electrolytes, renal function tests, liver function tests, TSHc | As clinically indicated |
| Pregnancy | Pregnancy test for women of childbearing potential | |
| Toxicology | Drug toxicology screen, if clinically indicated | Drug toxicology screen, if clinically indicated |
| Electrophysiological studies | EEG, if indicated on the basis of neurological exam or history | |
| Imaging | Brain imaging (CT or MRI, with MRI preferred), if indicated based on neurological exam or history | |
| Genetic testing | Chromosomal testing, if indicated on the basis of physical exam or history, including developmental history | |
| Monitoring for specific side effects of treatment | ||
| Diabetes | Screening for diabetes risk factors, fasting blood glucose | Fasting blood glucose or HbA1c four months after initiating a new treatment and at least annually thereafter |
| Hyperlipidemia | Lipid panel | Lipid panel four months after initiating a new antipsychotic medication and at least annually thereafter |
| Metabolic syndrome | Determine whether metabolic syndrome criteria are met | Determine whether metabolic syndrome criteria are met four months after initiating a new antipsychotic medication and at least annually thereafter. |
| QTcd prolongation | ECG before treatment with chlorpromazine, droperidol, iloperidone, pimozide, thioridazine, or ziprasidone or in the presence of cardiac risk factors | ECG with significant change in dose of chlorpromazine, droperidol, iloperidone, pimozide, thioridazine, or ziprasidone or with the addition of other medications that can affect QTc interval among patients with cardiac risk factors or elevated baseline QTc intervals |
| Hyperprolactinemia | Screening for symptoms of hyperprolactinemia; prolactin level, if indicated on the basis of clinical history | Screening for symptoms of hyperprolactinemia at each visit until stable, then yearly if treated with an antipsychotic known to increase prolactin; prolactin level, if indicated on the basis of clinical history |
| Antipsychotic-induced movement disorders | Clinical assessment of akathisia, dystonia, parkinsonism, and other abnormal involuntary movements, including tardive dyskinesia; Assessment with a structured instrument (e.g. AIMS, DISCUSe) if such movements are present | Clinical assessment of akathisia, dystonia, parkinsonism, and other abnormal involuntary movements, including tardive dyskinesia, at each visit. Assessment with a structured instrument (e.g. AIMS, DISCUS) at a minimum of every 6 months in patients at high risk of tardive dyskinesia and at least every 12 months in other patients as well as if a new onset or exacerbation of pre-existing movements is detected at any visit |
a
See table 2 of the full practice guideline for additional details.
b
CBC, complete blood count; ANC, absolute neutrophil count.
c
TSH, thyroid stimulating hormone.
d
QTc, corrected QT interval.
e
AIMS, Abnormal Involuntary Movement Scale; DISCUS, Dyskinesia Identification System–Condensed User Scale.
Given the high levels of morbidity, mortality, and health, social, occupational, and economic burdens of disease associated with schizophrenia, the Performance in Practice (PIP) Practice Assessment Tool for the Care of Patients With Schizophrenia was developed to assist psychiatrists in optimizing patient care and meeting Maintenance of Certification, part IV (MOC IV), requirements of the American Board of Psychiatry and Neurology and the American Board of Medical Specialties. It can also be used in partial fulfillment of Centers for Medicare & Medicaid Services Merit-based Incentive Payment System program requirements related to practice improvement activities (64). Continuing medical education information and directions for completing the activity are presented in Box 2.
BOX 2. CME information and directions for completing the activity
Completion of Stages A, B, and C in sequence is designated by the American Psychiatric Association for 20 AMA Physician’s Recognition Award (AMA PRA) category 1 credits. Begin date: October 1, 2020 - End Date: October 1, 2023
This activity is approved by the American Board of Psychiatry and Neurology for Maintenance of Certification, part 4, Clinical Module (PIP) until October 1, 2023
The course is completed online at education.psychiatry.org. APA members log in with their APA username and password. Nonmember FOCUS subscribers e-mail [email protected] to be enrolled in the online course.
Completion of three stages (A, chart review; B, improvement plan; and C, second chart review), evaluation of each stage, and credit claim for each stage of the Performance in Practice (PIP): Practice Assessment Tool for the Care of Patients With Schizophrenia takes place in the online course in the APA Education Portal, education.psychiatry.org.
The tool presented here is used to complete stages A and C and is available for download in the online course. Chart review data are for the use of the participant only and are not submitted to APA.
Three stages are involved in each PIP unit:
Stage A—the baseline retrospective chart review of at least five patients in the specified category, which is then compared with quality measures (i.e., published best practices, practice guidelines, peer-based standards).
Stage B—the design and implementation of a practice improvement plan
After comparing your recorded patient data with quality measures in stage A, you should initiate and document a plan for improvement. You may decide to access additional resources as part of your improvement plan. Your improvement plan is not submitted to APA but is for your own use.
Suggested interventions: For a more thorough presentation of specific clinical and psychosocial issues relating to the treatment of patients with schizophrenia, physicians and others interested in strengthening the quality of care provided to their patients with schizophrenia are strongly encouraged to carefully review the APA Practice Guideline for the Treatment of Patients With Schizophrenia (http://psychiatryonline.org/guidelines.aspx).
Other suggested activities and resources that may be used as part of your improvement plan include the following:
•
Use of specific recommendations and clinical resources outlined in stage A of the module.
•
FOCUS: The Journal of Lifelong Learning in Psychiatry, special issue on schizophrenia (Volume 18, Issue 4): review original articles and influential publications on schizophrenia published in this issue.
•
Continuing medical education course—APA Practice Guideline for the Treatment of Patients With Schizophrenia (www.apaeducation.org)
Stage C—subsequent remeasurement via a second chart review of five patients in the same category within 24 months after the initial chart review.
The American Psychiatric Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Physicians should claim only the credit commensurate with their participation in the activity.
The PIP tool draws on the structure and content of the 2012 version of the Performance in Practice: Physician Practice Assessment Tool for the Care of Adults With Schizophrenia (65). However, it has been significantly revised and updated on the basis of clinically significant evidence-based assessment and treatment recommendations from APA’s most recent Practice Guideline for the Treatment of Patients With Schizophrenia (66). This evidence-based guideline was developed through a systematic review of relevant literature and critical evaluation of the scientific research by experts in the assessment and treatment of schizophrenia. The guideline highlights critical issues related to evidence-based treatment and notes the importance of formulating a person-centered plan using shared decision making whenever possible, establishing a therapeutic alliance to identify barriers to the patient’s ability to participate in treatment, and engaging the patient’s family members and other significant support persons when able. Careful review of the full guideline is recommended to obtain additional details on assessment and treatment of individuals with schizophrenia.
In addition to providing key evidence-based recommendations that relate to the assessment and treatment of schizophrenia, the PIP tool is also intended to provide a simple retrospective chart review tool for physicians to determine whether their own assessment and treatment practices are consistent with the latest evidence-based recommendations and to offer valuable clinical resources related to screening, assessment, and treatment interventions, including possible ways to improve the clinical care of individuals with schizophrenia. In addition to its value as a self-assessment tool, this tool could also be used for peer review initiatives or broader systematic efforts by organizations and health care delivery systems to improve the assessment and treatment of patients with schizophrenia.
This PIP clinical tool has been designed to be relevant across different clinical settings, is straightforward to complete, and can be used in a pen-and-paper format to aid adoption. The PIP tool includes three sections related to patient assessment (Table 2); general treatment approaches, including both psychopharmacology and psychosocial treatments (Table 3); and treatments that are indicated by patient-specific needs and circumstances (Table 4). Each section highlights aspects of care that have significant public health implications or for which gaps in guideline adherence are common, as described earlier.
| Patient | |||||||
|---|---|---|---|---|---|---|---|
| Aspect of care and quality-related action | 1 | 2 | 3 | 4 | 5 | Total no. of patients with check mark in each rowb | Supporting evidence, resources, and clinical issues for consideration |
| 1. Were the patient’s reasons for seeking treatment, goals, view of the illness, and preferences for treatment identified as part of the assessment? | □ | □ | □ | □ | □ | __/5 | This information will provide a framework for recovery and serve as a starting point for person-centered care and shared decision making with the patient, family, and other support persons (67–69). Such discussions may also foster a more collaborative therapeutic relationship and promote adherence. Identification of goals and preferences should not be limited to symptom relief and may include goals related to schooling, employment, living situation, relationships, leisure activities, and other aspects of functioning and quality of life. |
| 2. Was a quantitative measure used as part of the initial evaluation to identify and determine the severity of symptoms and impairments of functioning? | □ | □ | □ | □ | □ | __/5 | The use of a quantitative measure as part of the assessment can help detect and determine the severity of psychosis and associated symptoms. Patient self-report ratings and clinician-based ratings can provide a structured replicable way to document baseline symptoms, determine which symptoms should be the target of intervention, and track whether nonpharmacological and pharmacological treatments are having their intended effect or whether a shift in the treatment plan is needed. A number of measures are available, as described in the full text of the guideline. The exact frequency at which measures are warranted will depend on clinical circumstances. |
| 3. Was the patient assessed for current or past tobacco use (including vaping)? | □ | □ | □ | □ | □ | __/5 | The rate of tobacco use is high among individuals with schizophrenia (47–49, 53, 56) and contributes to morbidity and mortality (57, 70–73). Screening to identify tobacco use is a crucial step in educating patients and providing treatment and follow-up using health education, motivational interviewing approaches (74), and smoking cessation guidelines for the general population (73, 75–78). Smoking also induces CYP1A2c and, with cessation (either intentionally or with admission to a smoke-free facility), there will be a corresponding increase in the levels of drugs metabolized via CYP1A2, including clozapine and olanzapine (79). |
| 4. Was the patient screened for use of cannabis, alcohol, and other substances? | □ | □ | □ | □ | □ | __/5 | Screening for use of cannabis, alcohol, and other substances is important because substance use is common (22, 45, 49, 50, 52, 54), can confound assessment of psychotic symptoms, and affect the course of schizophrenia (45, 80–82). It is important to determine whether the patient uses cannabis or other substances such as alcohol, caffeine, cocaine, opioids, sedative-hypnotic agents, stimulants, MDMA,d solvents, androgenic steroids, hallucinogens, or synthetic substances (e.g., “bath salts,” K2, Spice). The route by which substances are used (e.g., ingestion, smoking, vaping, intranasal, intravenous) is similarly important to document. SBIRTe can be integrated into a range of clinical settings (83, 84). In addition, assessment and screening for substance use disorders may include self-report corroborated by other sources such as family, friends, case managers, and treatment personnel and, as indicated, urine and blood toxicology and other tests such as liver function tests. |
| 5. Was the patient assessed for risk of suicide and other self-harming behaviors? | □ | □ | □ | □ | □ | __/5 | Suicidal ideas are common among individuals who have had a psychotic experience (85), and death from suicide has been estimated to occur in about 4%–10% of individuals with schizophrenia (10, 12, 16, 18–20). Thus, it is important to consider the risk of suicide and other self-harming behaviors in initial evaluations and follow-up assessments at all stages of illness. Assessment of the risk for suicidal behaviors typically includes asking the patient and, when possible, the patient’s family about prior suicidal behaviors and current or prior thoughts, plans, or intentions to harm or kill oneself (82). Risk assessment also requires synthesizing information gathered in the history and mental status examination and identifying modifiable risk factors for suicide that can serve as targets of intervention. |
| Patients with schizophrenia share the same risks for suicide fatalities and behaviors as the general population, including male sex, depressive symptoms, hopelessness, expressed suicidal ideation, a history of attempted suicide or other suicide-related behaviors, and the presence of alcohol use disorder or other substance use disorder (20, 86–90). Firearm access is an additional contributor to suicide risk (91–93). | |||||||
| Additional factors that have been identified as increasing risk for suicide among individuals with schizophrenia include auditory command hallucinations, agitation or motor restlessness, fear of mental disintegration, recent loss events, recency of diagnosis or hospitalization, repeated hospitalizations, high intelligence, young age, and poor adherence to treatment (8, 20, 86, 88, 94–96). | |||||||
| Despite identification of these risk factors, it is not possible to predict whether an individual patient will attempt or die by suicide. However, when an increased risk for such behaviors is present, it is important that the treatment plan reevaluate the care setting, address periods of increased risk (e.g., shortly after diagnosis, during incarceration, subsequent to hospital discharge), and implement approaches to target and reduce modifiable risk factors such as poor adherence, core symptoms of schizophrenia (e.g., hallucinations, delusions), co-occurring symptoms (e.g., depression, hopelessness, hostility, impulsivity), and co-occurring diagnoses (e.g., depression, alcohol use disorder, other substance use disorders). | |||||||
| 6. Was the patient assessed for risk of dangerous or aggressive behaviors, including interpersonal aggression and harm to others? | □ | □ | □ | □ | □ | __/5 | Akin to assessment for suicide and other self-harming behaviors, it is important to consider the risk of dangerous or aggressive behaviors in the initial evaluation and follow-up assessments at all stages of illness. Assessment of the risk for aggressive behaviors typically includes asking the patient and, when possible, the patient’s family about current or prior thoughts, plans, or intentions of aggression toward others. Many factors associated with a risk of aggression are similar to findings among individuals without psychosis and include male sex, young age, access to firearms, the presence of substance use, traumatic brain injury, a history of attempted suicide or other suicide-related behaviors, or prior aggressive behavior, including that associated with legal consequences (87, 90, 97–103). Among individuals with psychotic illnesses, prior suicidal threats, angry affect, impulsivity, hostility, recent violent victimization, childhood sexual abuse, medication nonadherence, and a history of involuntary treatment have also been associated with an increased risk of aggressive behavior (90, 97, 102, 103). Command hallucinations can be relevant when assessing individuals for a risk of aggressive behaviors (102, 104), and persecutory delusions may also contribute to aggression risk, particularly in the absence of treatment or in association with significant anger (102, 105, 106). |
| Despite identification of these risk factors, it is not possible to predict whether an individual patient will engage in aggressive behaviors. However, when an increased risk for such behaviors is present, it is important that the treatment plan reevaluate the care setting and implement approaches to target and reduce modifiable risk factors. | |||||||
| 7. Was the patient assessed for co-occurring psychiatric disorders and other co-occurring health conditions? | □ | □ | □ | □ | □ | __/5 | Many individuals with schizophrenia will have co-occurring psychiatric disorders, including SUDsf or other co-occurring health conditions. These disorders may affect treatment options or need to be addressed in the treatment plan. For example, if SUDs are identified, a comprehensive integrated treatment model is suggested to address both conditions. Alternatively, the treatment plan should address both disorders, and there should be communication and collaboration among treating clinicians. For patients who do not recognize the need for treatment of a substance use disorder, a stagewise motivational approach can be used (74, 107). |
| Individuals with schizophrenia may have experienced violent victimization (108–110) or childhood adversity (111–114), and PTSD should be identified and treated, if present (115–117). Depressive symptoms and anxiety are also common among individuals with schizophrenia and should be addressed as part of treatment planning. | |||||||
| Other health conditions are frequent in individuals with serious mental illness in general (8, 26, 118, 119) and those with schizophrenia in particular (120). Such disorders include but are not limited to poor oral health, hepatitis C infection, HIV infection, cancer, sleep apnea, obesity, diabetes mellitus, metabolic syndrome, and cardiovascular disease (8, 15, 26, 27, 121–127). These disorders, if present, can contribute to reduced quality of life or mortality (9–17). Also, some may influence choice of medication or may be induced or exacerbated by psychiatric medications. | |||||||
| Table 1 provides a discussion of suggested physical and laboratory assessments for patients with schizophrenia as part of initial evaluation and follow-up assessments. Such assessments are important to prevention, early recognition, and treatment of abnormalities such as glucose dysregulation, hyperlipidemia, metabolic syndrome, antipsychotic-induced movement disorders, and changes in cardiac conduction. It is also important that patients have access to primary care clinicians who can work with the psychiatrist to diagnose and treat concurrent physical health conditions (82). For women who are planning to become pregnant or who are pregnant or postpartum, it is essential to collaborate with the patient, her obstetrician-gynecologist or other obstetric practitioner, her infant’s pediatrician (if breastfeeding), and, if involved, her partner or other support persons. | |||||||
a
Instructions: Choose five adult patients from your current psychiatric caseload who meet diagnostic criteria for schizophrenia. Review their charts to determine whether they have received assessment and treatment that was consistent with key evidence-based recommendations shown in the left-hand column of this table. If yes, check the appropriate box; if no or unknown, leave the box unchecked. Note that the right-hand column provides supporting evidence, resources, and clinical issues that can be considered in relation to a specified recommendation. For additional details, the reader is directed to the full guideline (66).
b
Scoring: In the total column, tally the total number of check marks in each row. For any row for which the total is less than five, examine whether clinical or other circumstances explain why practice was not consistent with recommended care. Consider whether changes in your practice or use of any of the suggested clinical tools could strengthen the provision of evidence-based care.
c
CYP1A2, cytochrome P450 1A2.
d
MDMA, 3,4-methylenedioxy-methamphetamine.
e
SBIRT, screening, brief intervention, and referral to treatment.
f
SUDs, substance use disorders.
| Patient | |||||||
|---|---|---|---|---|---|---|---|
| Aspect of care and quality-related action | 1 | 2 | 3 | 4 | 5 | Total no. of patients with check mark in each rowb | Supporting evidence, resources, and clinical issues for consideration |
| 8. Was a comprehensive and person-centered treatment plan developed and documented that includes evidence-based nonpharmacological and pharmacological treatments? | □ | □ | □ | □ | □ | __/5 | In treating individuals with schizophrenia, a person-centered treatment plan should be developed and documented in the medical record. Discussion with the patient, other treating health professionals, family members, and others involved in the patient’s life can each be vital in developing a full picture of the patient and formulating a person-centered treatment plan, using shared decision making whenever possible. The overarching aims of treatment planning are severalfold: to promote and maintain recovery, to maximize quality of life and adaptive functioning, and to reduce or eliminate symptoms. It is essential to consider both nonpharmacological and pharmacological treatment approaches and recognize that a combination of nonpharmacological and pharmacological treatments will likely be needed to optimize outcomes. In addition, strategies to promote adherence are always important to consider in developing a patient-centered treatment plan (128). As treatment proceeds, the treatment plan will require iterative reevaluation and updating prompted by factors such as inadequate treatment response, difficulties with tolerability or adherence, impairments in insight, changes in presenting issues or symptoms, or revisions in diagnosis. Factors that influence medication metabolism (e.g., age, sex, body weight, renal or hepatic function, smoking status, use of multiple concurrent medications) may also require adjustments to the treatment plan, in terms of either typical medication doses or frequency of monitoring. Tailoring of the treatment plan may also be needed on the basis of sociocultural or demographic factors with the aim of enhancing quality of life or aspects of functioning (e.g., social, academic, occupational). Other elements of the treatment plan may include, but are not limited to, determining the most appropriate treatment setting, addressing risks of harm to self or others (if present), engaging family members and others involved in the patient’s life, educating patients and families about treatment options and community resources, collaborating with other treating clinicians, and addressing co-occurring conditions. |
| 9. Was treatment with an antipsychotic medication provided? | □ | □ | □ | □ | □ | __/5 | It is recommended that patients with schizophrenia be treated with an antipsychotic medication and, if symptoms improve, that antipsychotic treatment continue, generally with the same medication. The choice of a particular antipsychotic agent will typically occur in the context of discussion with the patient about the likely benefits and possible side effects of medication options and will incorporate patient preferences, the patient’s past responses to treatment (including symptom response and tolerability), the medication’s side effect profile, the presence of physical health conditions that may be affected by medication side effects, and other medication-related factors such as available formulations, potential for drug-drug interactions, receptor binding profiles, and pharmacokinetic considerations. Tables 3–9 in the full text of the guideline provide details on pharmacological properties of antipsychotic medications and can assist in the choice of an antipsychotic agent. If there is no significant improvement after several weeks of treatment (e.g., <20% improvement in symptoms) or if improvement plateaus before substantial improvement is achieved (e.g., >50% improvement in symptoms, minimal impairment in functioning), consider whether factors are present that would influence treatment response, such as concomitant substance use, rapid medication metabolism, poor medication absorption, interactions with other medications, or other effects on drug metabolism (e.g., smoking) that could affect blood levels of medication. If a patient has had minimal or no response to two trials of antipsychotic medication of two to four weeks duration at an adequate dose (129, 130), a trial of clozapine is recommended (see question 19 in Table 4). |
| 10. Was the patient monitored for changes in blood pressure and pulse during treatment with an antipsychotic medication? | □ | □ | □ | □ | □ | __/5 | For questions 10-13, assessments are needed during treatment to monitor physical status and detect specific side effects of antipsychotic treatment, as outlined in Table 1. In addition to the suggested monitoring frequency described in Table 1, modifications to monitoring frequency will depend on the clinical circumstances of the individual patient and will be influenced by the antipsychotic that is prescribed as well as by the patient’s history, preexisting conditions, and use of other medications in addition to antipsychotic agents. For example, screening for symptoms of hyperprolactinemia may be needed more frequently if the patient is treated with an antipsychotic known to increase prolactin, whereas an ECGc may be indicated with a significant change in dose of chlorpromazine, droperidol, iloperidone, pimozide, thioridazine, or ziprasidone or with the addition of other medications that can affect QTcd interval in patients with cardiac risk factors or elevated baseline QTc intervals. |
| 11. Was the patient monitored for changes in BMIe during treatment with an antipsychotic medication? | □ | □ | □ | □ | □ | __/5 | |
| 12. Was the patient monitored for metabolic syndrome during treatment with an antipsychotic medication? | □ | □ | □ | □ | □ | __/5 | |
| 13. Was the patient monitored for antipsychotic-induced movement disorders (acute dystonia, akathisia, parkinsonism, tardive syndromes) during treatment with an antipsychotic medication? | □ | □ | □ | □ | □ | __/5 | |
| 14. Was CBTpf offered? | □ | □ | □ | □ | □ | __/5 | The use of CBTp for individuals with schizophrenia has several potential benefits, including improvements in quality of life and global, social, and occupational function and reductions in core symptoms of illness, such as positive symptoms. CBTp focuses on guiding patients to develop their own alternative explanations for maladaptive cognitive assumptions, which are healthier and realistic and do not perpetuate the patient’s convictions regarding the veracity of delusional beliefs or hallucinatory experiences. CBTp can be started in any treatment setting, including inpatient settings, and during any phase of illness (131), although some initial reduction in symptoms may be needed for optimal participation. It can also be conducted in group and individual formats, either in person or via Web-based delivery platforms. At organizational or health system levels, attention to enhancing the availability of CBTp is important given the limited availability of CBTp in the United States. |
| 15. Was patient psychoeducation provided? | □ | □ | □ | □ | □ | __/5 | Elements of psychoeducation are an integral part of good clinical practice and include providing the patient with education about the differential diagnosis, risks of untreated illness, treatment options, and benefits and risks of treatment (82). More formal psychoeducation is also recommended, in either an individual or a group format, often in conjunction with family members or other individuals who are involved in the patient’s life. Typically, psychoeducation involves approximately 12 sessions and incorporates multiple educational modalities such as workbooks (132), pamphlets, videos, and individual or group discussions to achieve its goals. Information commonly conveyed in a psychoeducation program includes key information about diagnosis, symptoms, psychosocial interventions, medications, and side effects as well as information about stress and coping, crisis plans, early warning signs, and suicide and relapse prevention (133). Information that may be useful to patients and families as a part of psychoeducation is available through SMI Adviser (smiadviser.org/). |
| 16. Was the patient offered family interventions? | □ | □ | □ | □ | □ | __/5 | An important aspect of good psychiatric treatment is involvement of family members, support persons, and other individuals who play a key role in the patient’s life. These individuals include spouses, parents, children, or other biological or nonbiological relatives; people who reside with the patient; intimate partners; or close friends who are an integral part of the patient’s support network. Such individuals benefit from discussion of topics such as diagnosis and management of schizophrenia, types of support that are available, and ways to plan for and access help in a crisis. Other goals include helping individuals repair or strengthen their connections with family members and other members of their support system. |
| Most patients want family to be involved in their treatment (134). However, even when a patient does not want a specific person to be involved in the patient’s care, the clinician may listen to information provided by that individual, as long as confidential information is not provided to the informant (82). General information that is not specific to the patient can be provided (e.g., common approaches to treatment, general information about medications and their side effects, available support and emergency assistance). Also, to prevent or lessen a serious and imminent threat to the health or safety of the patient or others, the Principles of Medical Ethics (135) and HIPAAg (136, 137) permit clinicians to disclose necessary information about a patient to family members, caregivers, law enforcement, or other persons involved with the patient. HIPAA also permits health care providers to disclose necessary information to the patient’s family, friends, or other persons involved in the patient’s care or payment for care when such disclosure is judged to be in the best interests of the patient and the patient is not present or is unable to agree or object to a disclosure because of incapacity or emergency circumstances (137). | |||||||
| Family interventions go beyond the basics of family involvement and illness education that are important for good clinical care. Family interventions can be delivered in a variety of formats and approaches (138, 139) and have the greatest benefits when more than 10 treatment sessions are systematically delivered over a period of at least seven months (138). They may include structured approaches to problem solving, training in how to cope with illness symptoms, assistance with improving family communication, provision of emotional support, and strategies for reducing stress and enhancing social support networks (138–140). Guidance is available on developing family intervention programs focused on psychoeducation (141, 142). In addition, the National Alliance on Mental Illness has the Family-to-Family program, which has led to a significant expansion in the availability of family interventions (143, 144). | |||||||
| 17. Were self-management skills and recovery-focused interventions offered? | □ | □ | □ | □ | □ | __/5 | Illness self-management training programs have been applied to help address many chronic conditions and are designed to improve knowledge about one’s illness and management of symptoms (145). Goals include reducing the risk of relapse, recognizing signs of relapse, developing a relapse prevention plan, and enhancing coping skills to address persistent symptoms with the aim of improving quality of life and social and occupational functioning. Evidence suggests better outcomes among patients who participate in at least 10 self-management intervention sessions. Self-management sessions are typically facilitated by clinicians, although peer-facilitated sessions have also been used. In addition, individually targeted interventions, either face to face or via computer-based formats (146), have been used. |
| Recovery-focused interventions have also been developed that focus on fostering self-determination in relation to a patient’s personal goals, needs, and strengths. Such approaches may include elements of self-management skill development, psychoeducation, and peer-based interventions but also include components and activities that allow participants to share experiences and receive support, learn and practice strategies for success, and identify and take steps toward reaching personal goals. | |||||||
| A tool kit for developing illness management and recovery-based programs in mental health is available (147). Other available resources are also described in the full text of the guideline and at SMI Adviser (smiadviser.org/individuals-families). | |||||||
| 18. Were supported employment services offered? | □ | □ | □ | □ | □ | __/5 | Evidence consistently shows that supported employment is associated with a greater rate of competitive employment. Other benefits of supportive employment include greater number of hours worked per week, a longer duration of each job, a longer duration of total employment, and an increase in earnings (138). Individuals receiving supported employment are also more likely to obtain job-related accommodations than individuals with mental illness who are not receiving supported employment (148). Such accommodations typically relate to support from the supported employment coach but may also include flexible scheduling, reduced hours, modified job duties, and modified training and supervision. |
| Supported employment differs from other vocational rehabilitation services in providing assistance in searching for and maintaining competitive employment concurrently with job training, embedded job support, and mental health treatment (149–151). For individuals whose goals are related to educational advancement before pursuit of employment, supported educational services may also be pursued (152). | |||||||
| For clinicians and organizations that want to learn more about supported employment or develop supported employment programs, additional information is available through SMI Adviser (smiadviser.org/), Navigate (navigateconsultants.org/manuals/), and the Boston University Center for Psychiatric Rehabilitation (cpr.bu.edu/). | |||||||
a
Instructions: Choose five adult patients from your current psychiatric caseload who meet diagnostic criteria for schizophrenia. Review their charts to determine whether they have received assessment and treatment that was consistent with key evidence-based recommendations shown in the left-hand column of this table. If yes, check the appropriate box; if no or unknown, leave the box unchecked. Note that the right-hand column provides supporting evidence, resources, and clinical issues that can be considered in relation to a specified recommendation. For additional details, the reader is directed to the full guideline (66).
b
Scoring: In the total column, tally the total number of check marks in each row. For any row for which the total is less than five, examine whether clinical or other circumstances explain why practice was not consistent with recommended care. Consider whether changes in your practice or use of any of the suggested clinical tools could strengthen the provision of evidence-based care.
c
ECG, electrocardiogram.
d
QTc, corrected QT interval.
e
BMI, body mass index.
f
CBTp, cognitive-behavioral therapy for psychosis.
g
HIPAA, Health Insurance Portability and Accountability Act.
| Patient | |||||||
|---|---|---|---|---|---|---|---|
| Aspect of care and quality-related action | 1 | 2 | 3 | 4 | 5 | Total no. of patients with check marks OR circled NAs in each rowb | Supporting evidence, resources, and clinical issues for consideration |
| 19. Clozapine, for individuals with treatment-resistant symptoms | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Clozapine should be offered to individuals with schizophrenia who have treatment-resistant schizophrenia because its use is associated with a higher rate of treatment response, reduction in psychotic symptoms, and lower rates of all-cause mortality, hospitalization, and treatment discontinuation resulting from lack of efficacy (138). A common definition of treatment-resistant schizophrenia is that a patient’s symptoms have shown no response or partial and suboptimal response to two antipsychotic medication trials of at least six weeks each at an adequate dose of medication, and some definitions specify using medications from different classes (e.g., second-generation antipsychotic vs. first-generation antipsychotic). However, if there is no significant improvement after several weeks of treatment (e.g., <20% improvement in symptoms), the likelihood of substantial improvement (e.g., >50% improvement in symptoms) is small (129, 130), and a longer trial of the medication may not be warranted. It should also be noted that a medication trial cannot be viewed as adequate if it is truncated in terms of duration or dosage because of poor tolerability or if limited by poor adherence. |
| 20. Clozapine, for individuals with a substantial risk for suicide attempts or suicide despite other treatments | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Regardless of whether criteria for treatment-resistant schizophrenia are met, clozapine should be offered to individuals with schizophrenia who have substantial risk for suicide attempts or suicide despite other treatments because clozapine use is associated with lower rates of self-harm, suicide attempts, and hospitalizations to prevent suicide (138). |
| 21. Clozapine, for individuals with a substantial risk for aggressive behavior despite other treatments | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Although evidence is less robust than for use of clozapine for treatment-resistant schizophrenia or persistent risk of suicide, treatment with clozapine can also be effective in reducing aggressive behavior. As in other circumstances in which patients do not appear to be responding fully to treatment, attention to adherence is crucial. |
| 22. An LAIc antipsychotic, for individuals with a history of poor or uncertain adherence, or a preference for LAI treatment | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | An LAI formulation of an antipsychotic medication is suggested for individuals with schizophrenia who prefer LAI medication or have a history of poor or uncertain adherence. In addition to patients who have had difficulty in adhering to oral medications, this may include individuals who have limited awareness of having an illness, who have not responded to treatment with an oral medication, who have a history of frequent relapses on oral medication, or who are transitioning between treatment settings where adherence may be difficult. Although randomized controlled trials do not show evidence of benefit from LAIs relative to oral antipsychotic medications, observational data from nationwide registry databases, cohort studies, and “mirror image” studies suggest that use of LAI antipsychotic agents as compared with oral antipsychotic medications is associated with a decreased risk of mortality, reduced risk of hospitalization, and decreased rates of study discontinuation, including discontinuation due to inefficacy (153–158). Thus, the benefits associated with use of an LAI formulation of an antipsychotic medication are at least as good as the benefits of an oral formulation and may be better, with no significant differences in side effects between oral and LAI formulations. |
| 23. Anticholinergic medications, for individuals with acute dystonia associated with antipsychotic therapy | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Clinical experience suggests that acute dystonia can be ameliorated by administration of diphenhydramine, a histamine receptor antagonist with anticholinergic properties. Typically, it is administered intramuscularly to treat acute dystonia, but it can also be administered intravenously in emergent situations, as with acute dystonia associated with laryngospasm. Alternatively, benztropine can be administered intramuscularly. Once the acute dystonia has resolved, it may be necessary to continue an oral anticholinergic medication such as benztropine or trihexyphenidyl to prevent recurrence, at least until other changes in medications can take place, such as reducing the dose of medication or changing to an antipsychotic medication that is less likely to be associated with acute dystonia. Whenever an anticholinergic medication is prescribed, it is important to be mindful of the potential for medication side effects and interactions with other medications that a patient is taking. |
| 24. Medication changes, for individuals with parkinsonism associated with antipsychotic therapy | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | For patients who have parkinsonism associated with antipsychotic therapy, the following options can be considered: lowering the dosage of the antipsychotic medication, switching to another antipsychotic medication, or treating with an anticholinergic medication. However, before reducing the dose of medication or changing to another antipsychotic medication, the benefits of reduced parkinsonism should be weighed against the potential for an increase in psychotic symptoms. The use of an anticholinergic medication is another option, either on a short-term basis, until a change in dose or a change in medication can occur, or on a longer term basis, if a change in dose or change in medication is not feasible. It should be noted that different symptoms of parkinsonism (e.g., rigidity, tremors, akinesia) may have a differential response to anticholinergic medications, and different treatment approaches may be needed to address each of these symptoms. If an anticholinergic medication is prescribed, it is important to be mindful of the potential for medication side effects and interactions with other medications that a patient is taking. |
| 25. Medication changes, for individuals with akathisia associated with antipsychotic therapy | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | For patients who have akathisia associated with antipsychotic therapy, the following options can be considered: lowering the dosage of the antipsychotic medication, switching to another antipsychotic medication, adding a benzodiazepine medication, or adding a beta-adrenergic blocking agent. In contrast, akathisia tends not to respond to anticholinergic agents (159). Before reducing the dose of medication or changing to another antipsychotic medication, the benefits of reduced akathisia should be weighed against the potential for an increase in psychotic symptoms. In addition, it is important to assess for dysphoria, which may be associated with akathisia, and to distinguish between akathisia and restlessness or agitation associated with anxiety or psychosis. |
| 26. VMAT2d medications, for individuals with moderate to severe or disabling tardive dyskinesia | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Evaluation for the presence of tardive syndromes is important to identify them, minimize worsening, and institute clinically indicated treatment. Regular assessment of patients for tardive syndromes through clinical examination or use of a structured evaluative tool (e.g., AIMS, DISCUSe) can aid in identifying tardive syndromes, clarifying their likely etiology, monitoring their longitudinal course, and determining the effects of medication changes or treatments for tardive dyskinesia (see Table 1). If no contributing etiology is identified, as discussed in the full text of the guideline, and moderate to severe or disabling tardive dyskinesia persists, treatment is recommended with a reversible VMAT2 inhibitor. Treatment with a VMAT2 inhibitor can also be considered for patients with mild tardive dyskinesia on the basis of factors such as patient preference, associated impairment, or effect on psychosocial functioning. In general, deutetrabenazine or valbenazine are preferred over tetrabenazine because of the greater evidence base supporting their use. However, tetrabenazine and deutetrabenazine are contraindicated for individuals with hepatic impairment, whereas valbenazine is not recommended for use with individuals with severe renal impairment. In addition, anticholinergic medications are not helpful and may worsen tardive dyskinesia (160). |
| 27. CSCf program (e.g., NAVIGATE/RAISE), for individuals experiencing a first episode of psychosis | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | CSC programs, which are sometimes referred to as team-based, multicomponent interventions, provide a comprehensive package of treatment that integrates collaborative, shared decision making with approaches such as family involvement and education, individual resiliency training, supported employment and education, and individualized medication treatment (161, 162). Similar CSC programs have also been used for treatment of early psychosis (163–165). When CSC programs are unavailable, advocacy may be needed to encourage program development; materials are available to help guide the establishment of new programs with evidence-based approaches (162, 166, 167). |
| 28. ACT,g for individuals with a history of poor engagement with services leading to frequent relapse or social disruption (e.g., homelessness, legal issues) | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | ACT is a multidisciplinary, team-based approach in which patients receive personalized and flexible care outside of a formal clinical setting with the aim of addressing patients’ needs and preferences without time limits or other constraints on services. Because availability of ACT programs is often limited, advocacy may be needed to encourage program development and high fidelity to ACT program standards (168–171). |
| 29. Supportive psychotherapy, for individuals who are not able to receive or prefer not to receive an evidence-based psychotherapy for psychosis | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Supportive psychotherapy is commonly a part of the treatment plan for individuals with schizophrenia who are not receiving other modes of psychotherapy (e.g., CBTph). Supportive psychotherapy commonly aims to help patients cope with symptoms, improve adaptive skills, and enhance self-esteem. Examples of techniques used to foster these goals include reassurance, praise, encouragement, explanation, clarification, reframing, guidance, suggestion, and use of a conversational, nonconfrontational style of communication. Many of the common elements that have been identified in effective psychotherapies, including a positive therapeutic alliance, are also integral to supportive psychotherapy (172, 173). Because the evidence related to its benefits is limited, supportive psychotherapy should not take precedence over other evidence-based psychosocial treatments (e.g., coordinated specialty care, CBTp, psychoeducation). |
| 29. Cognitive remediation, for individuals with cognitive difficulties | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Cognitive remediation approaches are intended to address cognitive difficulties that can accompany schizophrenia with the aim of enhancing function and quality of life. A number of different cognitive remediation approaches have been used, typically in group- or computer-based formats, in an effort to enhance cognitive processes such as attention, memory, executive function, social cognition, or meta‐cognition (174–178). Some programs add aspects of social and communication skills to neurocognitive elements of remediation (179). The primary barriers to use of cognitive remediation are related to program availability. Advocacy may be needed to encourage program development (174, 178). Web-based programs have been used in clinical trials and may provide options for patients without access to in-person programs (180, 181). |
| 30. Social skills training, for individuals who have a therapeutic goal of enhanced social functioning | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Social skills training has an overarching goal of improving interpersonal and social skills, but it can also improve core illness symptoms and negative symptoms more than usual care (138). Social skills training can include cognitive-behavioral, social-cognitive, interpersonal, and functional adaptive skills training (55, 182, 183). It is delivered in a group format and includes homework assignments to facilitate skill acquisition. In some social skills training programs, group sessions are augmented with video or technologically based interventions, community trips to practice social skills (184, 185), and involvement of support people who are accessible, pleasant, and knowledgeable about the local environment’s resources and limitations (185, 186). Advocacy may be needed to encourage program development; information about social skills training is available for organizations that want to develop such programs (187–189). |
a
A number of other evidence-based interventions are important to consider when developing treatment plans because they have been shown to be beneficial to patients with specific needs or in specific clinical circumstances. If the index intervention was provided or offered to the select patient, please check the appropriate box; if no or unknown, leave the box unchecked. If the patient does not qualify to receive the indicated intervention, please circle NA.
b
Scoring: In the total column, tally the total number of check marks and circled NAs in each row. For any row for which the total is less than five, examine whether clinical or other circumstances explain why practice was not consistent with recommended care or whether the indicated treatment is not currently available and therefore not applicate for the patient. Consider whether changes in your practice could strengthen the provision of evidence-based care or whether advocacy efforts are needed to make evidence-based services more available. NA, not applicable.
c
LAI, long-acting injectable.
d
VMAT2, vesicular monoamine transporter 2.
e
AIMS, Abnormal Involuntary Movement Scale; DISCUS, Dyskinesia Identification System: Condensed User Scale.
f
CSC, coordinated specialty care.
g
ACT, assertive community treatment.
h
CBTp, cognitive-behavioral therapy for psychosis.
The left column of the tool inquires whether a specific quality-related action was taken. The middle portion of the tool provides checkboxes to record whether the action was taken for up to five patients who are being reviewed. It is important to note that the American Board of Psychiatry and Neurology MOC IV program requires review of at least five patients as part of each PIP unit; however, larger samples will provide a more accurate estimate of the quality of care within a practice. The last column of the tool provides guideline-supported recommendations and clinical resources to assist in identifying knowledge gaps and engaging in practice improvement efforts.
After using the PIP tool to assess the pattern of care provided to patients, the physician should determine whether specific aspects of care need to be improved. Assessment and treatment recommendations provided in the practice guidelines are generally intended to be relevant to the majority of individuals. However, patients vary widely in their preferences for treatment, clinical presentation, history of treatment and prior response, presence of co-occurring physical and psychiatric conditions, and other factors that may influence clinical decision making. Because patients with schizophrenia have high levels of complex symptomatology and co-occurring psychiatric and other medical comorbidities, divergence from evidence-based recommendations may occur. Deviations from guidelines may also arise when recommended treatments have been tried but have not led to full response of symptoms or return to baseline levels of functioning. In addition, practice guidelines and quality indicators are often derived from findings of efficacy and effectiveness trials in which stringent enrollment criteria are used; thus, individuals in clinical trials often differ in important ways from those seen in routine clinical practice. Although this tool is intended to highlight current evidence-based assessment and treatment recommendations for patients with schizophrenia, justifiable variations from recommended care may occur.
Guided by the PIP tool findings and a subsequent practice assessment, physicians may determine that deviations from the quality indicators are clinically appropriate and justified, or they may choose to acquire new knowledge and modify their practice to improve quality. For example, if patients with schizophrenia in a physician’s current psychiatric caseload are not routinely screened for tobacco or other substance use, an area for improvement could involve implementation of systematic screening for alcohol and tobacco use, which is especially common among patients with schizophrenia. Use of the PIP tool may also highlight potential treatment service gaps, which may include, for example, lack of availability of cognitive-behavioral therapy for psychosis, assertive community treatment, substance use treatment services, or supported employment programs. It is hoped that this tool, together with the evidence-based guideline, may be useful in optimizing use of evidence-based treatment and advocating for increased availability of critically needed core services to help improve the lives and functioning of individuals with schizophrenia.
Acknowledgments
The authors acknowledge the contributions of the members of the writing group for the American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia, Third Edition (George A. Keepers, M.D., chair), the American Psychiatric Association Committee on Practice Guidelines (Daniel J. Anzia, M.D., Chair), and the contributions of APA staff and former staff, including Farifteh Duffy, Samantha Shugarman, Michelle Dirst, and Kristin Kroeger Ptakowski.
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