For comparison purpose, Table 1 presents CPGs pertaining to biological strategies from the various groups. This table includes an overview of the pharmacotherapeutic strategies, management of medication side effects, the role of electroconvulsive therapy, and the management of comorbid conditions. Due to wide variation in the CPGs pertaining to psychosocial interventions, the recommendations are summarized later.

A stumbling block among the various evaluated guidelines is the inconsistency as to what constitutes the stable phase of schizophrenia. For example, the APA guidelines define stable phase as “characterized by absent or low-grade symptoms.” In addition, any symptoms if present, “may often be present in attenuated, nonpsychotic forms”. In contrast, the Canadian Psychiatric Association (CPA) guidelines suggest that the stable or chronic phase is “one in which acute symptoms may have subsided, but functioning is often much impaired.” (Italics are added for emphasis.) The French guidelines of the Agence Nationale Pour le Development de L’Evaluation Medicale (ANDEM) conceptualize the illness as occurring in 3 phases, with the stabilization phase occurring from age 30 to 35 years up to age 55 years, only after which the stable phase sets in. The Expert Consensus, the TMAP, and the PORT guidelines do not clearly define the stable phase, relying instead on readers to use their own understanding of the concept. Obviously, no clear all-encompassing definition or measurement will suitably quantify the various stages of the disorder (unlike, say, blood pressure measurements, as defined in CPGs for antihypertensive therapy). However, uniform definitions are important to avoid ambiguity and uncertainty when applying the treatment guidelines. We therefore suggest that, to maintain consistency, uniform definition of the stable phase be adopted; organizations such as the World Health Organization may need to take a lead in this area.

When assessing the guidelines, various perspectives are obvious. For instance, the TMAP guidelines are concerned almost

exclusively with providing pharmacotherapeutic algorithms, with minimal emphasis on psychosocial interventions. In contrast, the French CPGs are broader and more philosophical in their outlook. While these approaches give unique perspectives to each series of guidelines, they may lead to overemphasis in certain areas and the risk of neglecting others. Therefore, interested parties, particularly nonclinicians, should be cautious when referring to individual guidelines to aid decisions. This caution is particularly relevant as more third-party payers use guidelines to justify reimbursement schemes. There are other unique features to each series of guidelines. For instance, the Expert Consensus Guidelines provide an excellent patient and family guide prepared in collaboration with the National Alliance for the Mentally Ill. The TMAP algorithms are notable for having clear and easy-to-follow algorithms presented in a table format, which allows one to sequentially follow the recommendations. Both the PORT (7) and the APA (8) guidelines are well researched and referenced, hence providing clinicians with primary references.

Few discrepancies are evident among the CPGs, partly as a result of shared background information. For example, the APA, the CPA, and the PORT guidelines all accept typical and atypical agents for first-line use to treat schizophrenia (Table 1). The ANDEM group is unique in that differences are recognized among the typical and atypical agents; for this reason, the choice of medication and polypharmacy is left to the clinician. The Expert Consensus Guidelines, revised since their first publication in 1996, place a greater emphasis on the use of atypical agents as first-line therapy for all patients with the disorder (notable exceptions include patients who are on depot agents or patients well stabilized on typical antipsychotic agents). The TMAP guidelines, also using background research done by other organizations, emphasize atypical agents as their primary choice. The preferential use of atypical agents is a trend evident amongst the more recently published guidelines (6,9).