Management strategies for extrapyramidal symptoms (EPS) have also undergone revision. Whereas earlier CPGs, PORT, APA, and ANDEM emphasized prophylaxis management of EPS, the more recently published guidelines, Expert Consensus, and TMAP, favour the use of atypical agents to prevent EPS (Table 1). For example, the Expert Consensus Guidelines discourage the use of anticholinergic agents; however, the ANDEM and the APA guidelines discuss the rationale for anticholinergic use. As more information accumulates on the role of atypical agents, revisions to the older guidelines are to be expected. An area inadequately addressed by the newer series of CPGs is the area of side-effect management with the newer atypical agents. Concerns about weight gain, hyperlipidemia, diabetes, and sexual dysfunction have not been adequately addressed. For instance, should all patients commencing atypical agents receive regular monitoring of their weight and blood sugar? Should dietary counselling form part of psychosocial interventions with patients receiving newer atypical agents? These are concerns that face clinicians regularly as they switch more patients to atypical antipsychotics. Comorbid conditions are covered to varying degrees among the CPGs evaluated.
An obvious variation among the CPGs is the recommendation on appropriate duration of medication trial (Table 1). The length of medication trial ranges from a minimum of 3 weeks (Expert Consensus) to a minimum of 6 weeks (PORT), depending on the CPGs studied. In theory, the shorter trial period enables a shorter waiting period for nonresponders to be considered for clozapine therapy. In addition, a lengthy medication trial period can theoretically delay the time it takes to achieve the stable phase. Clearly, these variations need to be addressed to maintain consistency.
An important component of schizophrenia management includes psychosocial treatments. These are covered nonuniformly among the various guidelines examined. The TMAP CPGs do not discuss psychosocial interventions. The APA guidelines provide a comprehensive discussion in the domains of individual, family, and group therapies. Individual psychotherapy in the form of supportive and reality-based therapy is emphasized. Other guidelines are provided for early intervention, assertive community treatment, social skills training, vocational training, and self-help programs. The Canadian guidelines are similar but presented in less detail. Rehabilitation issues specific to the stable phase are provided, for example, in vocational support, substance-use management, and rehabilitation setting. According to the Expert Consensus Guidelines, interventions should be tailored to the severity of the illness and the degree of impairment in the residual period. Rehabilitation services (such as structured programs for living, working, learning, and social environments) should be prioritized for patients with a moderate degree of impairment, compared with patients following a single episode, presumably because of the relatively higher level of functioning for patients following a simple episode. CPGs are also provided for staff–patient ratios based on the degree of impairment. High staffing coverage should be provided for severely impaired patients compared with low-to-moderate coverage for stable patients (6). The Expert Consensus group also provides practical suggestions, such as 24-hour telephone contact for the patient recently discharged from the hospital. Diverse interventions are therefore considered under the rubric of psychosocial interventions.
The PORT guidelines are broad in their coverage of psychosocial approaches and are based on the formats of psychological and family treatments, vocational rehabilitation, and service delivery systems. Psychological treatments recommended by the PORT group include behavioural and cognitive for the individual patient and psychoeducation and problem solving for the family unit during all stages of the disorder. Coverage of vocational rehabilitation and service systems (that is, assertive community treatment, particularly for patients with frequent use of the health care system) is also provided. The French ANDEM CPGs stress the importance of psychosocial rehabilitation on an ongoing, time-unlimited basis. Discussion is also provided on quality-of-life issues with antipsychotic therapy, such as disfigurement with tardive dyskinesias and cognitive impairment. Ethical concerns, notably issues of informed consent and enforced commitment, are also raised (10). An area of inconsistency noted among the various CPGs is the issue of individual
psychotherapy using a psychoanalytic psychodynamic approach. Both the Expert Consensus (6) and the PORT (7) groups regard psychodynamic therapy as contraindicated in schizophrenia. The CPA guidelines (5) do not to address this issue. In contrast, the French (10) and the APA (8) CPGs suggest that psychoanalytically oriented individual psychotherapy be decided on a case-by-case basis, particularly for patients who are highly motivated and who are in the stable phase.
The field of schizophrenia research and practice has experienced tremendous progress over the past decade, and this is reflected in the evolution of the CPGs. All guidelines consistently emphasize antipsychotic therapy as a keystone for the management of the illness. In addition, all groups recognize the need for psychosocial interventions as critical. However, some notable differences are evident: for instance, there has been a shift toward the use of atypical antipsychotics as first-line agents. Similarly, the duration of medication trial period has decreased by one-half to a period of 3 weeks in the more recent CPGs. An area that has not been addressed suitably is the definition of the stable phase of the disorder. In the realm of psychosocial interventions, the need for active engagement of the patient individually, with the family, and in groups is also important, yet differences are present with respect to the form of individual psychotherapy. Further CPGs are required to address the issue of side-effect management with the newer atypical agents. Other gaps present in the guidelines, such as management of clozapine nonresponders or the management of personality characteristics during the illness, need further research and clarification.
References1. Institute of Medicine Committee to Advise the Public Health Service on Clinical Practice Guidelines. Clinical practice guidelines: directions for a new program. Washington (DC): National Academic Press; 1990.
2. McCormick KA, Felming B. Clinical practice guidelines. Health Progress 1992;12:30.
3. Smith TE, Docherty JP. Standards of care and clinical algorithms for treating schizophrenia. Psychiatr Clin North Am 1998;21:203– 20.
4. Addington DA, el Guebaly N, Chandarana P, Atkinson M. Canadian clinical practice guidelines for the treatment of schizophrenia adherence and awareness. CPA Bulletin 2000;32:164.
5. Bassett A, Addington D. Canadian clinical practice guidelines for the treatment of schizophrenia. Can J Psychiatry 1998;43 (Suppl 2).
6. McEvoy JP, Scheifler PL, Frances A. The expert consensus guideline series: treatment of schizophrenia 1999. J Clin Psychiatry 1999;60 (Suppl 11).
7. Lehman AF, Steinwachs DM. The schizophrenia patient outcomes research team (PORT) treatment recommendations. Schizophr Bull 1998;24(l):1–10.
8. American Psychiatric Association. Practice guidelines for the treatment of patients with schizophrenia. Am J Psychiatry 1997;154 (Suppl 4).
9. Miller AL, Chiles JA, Chiles JK, Crismon ML, Rush AJ, Shon SP. The Texas medication algorithm project (TMAP) schizophrenia algorithms J Clin Psychiatry 1999;60:649–57.
10. Agence Nationale Pour le Development de L’Evaluation Medicale. Strategies therapeutiques a long terme dans les psychoses schizophreniques. Texte du consensus. Paris: Agence Nationale pour le Development de L’Evaluation Medicale; 1994.
11. Glikman J, Lazart L, Casadebaig F, Philippe A, Lachaux B, Kovess V. Etude de l’impact de la conference de consensus “Strategies therapeutiques a long terme dans les psychoses schizophreniques.”. L’Encephale 1999;25:558 68.
Manuscript received March 2001, revised, and accepted January 2002.