A new set of evidence-based practice guidelines for the treatment of patients with schizophrenia has been released by the American Psychiatric Association, with the goal of reducing the significant consequences the disorder has on individuals. Here, Laura J. Fochtmann, MD, MBI, a member of the practice guidelines writing group, shares some insights into the guidelines and how they may impact clinical practice, and discusses future research needs related to schizophrenia.
Q: Why was an update of the schizophrenia practice guidelines needed?
A: Since the prior edition of APA’s Practice Guideline for Treatment of Patients with Schizophrenia, there has been a considerable amount of research on psychosocial interventions for schizophrenia. There has also been new research on pharmacotherapies as well as the addition of new antipsychotic agents and new treatments for tardive dyskinesia to our therapeutic options.
Q: What are the most substantial changes from the last set of guidelines?
A: This edition of the practice guideline gives additional emphasis on the importance of shared decision-making and patient preferences in developing a comprehensive person-centered plan of treatment that includes antipsychotic medication as well as an array of evidence-based psychosocial interventions. Quantitative measures (such as rating scales of psychiatric symptoms, functioning or quality of life) are recommended as part of the initial evaluation and can also help track whether treatment is effective over time.
The more recent evidence also highlights the benefits of coordinated specialty care programs for individuals who are experiencing a first episode of psychosis. It also recommends that patients with schizophrenia receive cognitive-behavioral therapy for psychosis, psychoeducation, and supported employment services.
In terms of medications, the new edition of the guideline includes detailed tables of antipsychotic characteristics to help clinicians and patients individualize and optimize medication choices. It also emphasizes the circumstances in which use of clozapine or a long-acting injectable antipsychotic medication may improve outcomes. The availability of additional reversible inhibitors of the vesicular monoamine transporter 2 (VMAT2) is also new in this edition of the guideline for individuals who have moderate to severe or disabling tardive dyskinesia associated with antipsychotic therapy.
Q: What do the guidelines recommend regarding long-acting injectables, and why?
A: The guideline suggests that patients receive treatment with a long-acting injectable (LAI) antipsychotic medication if they prefer such treatment or if they have a history of poor or uncertain adherence. Because LAI antipsychotics deliver the necessary dose of medicine over time, there are fewer opportunities to forgot or miss a medication dose. In addition to being more convenient than oral medications for many patients, they can be especially helpful for individuals who have not responded to treatment with an oral medication, who have a history of frequent relapses on oral medication, who have limited awareness of having an illness, or who are transitioning between treatment settings where adherence may be difficult.
Q: How do you expect these guidelines to affect routine clinical practice?
A: We hope that clinicians, patients, and families, as well as policy makers and health care organizations will use the guidelines to assure that individuals with schizophrenia are receiving evidenced-based care that spans comprehensive treatment planning, medication therapies, and psychosocial interventions. Although clozapine and LAI antipsychotic medications were available at the time of the last guideline, many patients remain symptomatic yet have not been offered treatment with these options. In addition, many effective psychosocial interventions have yet to be incorporated into common use.
We also know that individuals with schizophrenia have an increase in morbidity and mortality that is likely associated with such factors as obesity, diabetes, hyperlipidemia, greater use of cigarettes, reduced engagement in health maintenance (eg, diet, exercise), and disparities in access to preventive health care and treatment for physical conditions. Thus, we expect that health benefits would result from greater attention to the guideline’s recommendations for monitoring factors such as vital signs, weight change, diabetes, or lipid levels.
Q: What areas do you think future research on schizophrenia treatment should focus on?
A: There is a multiplicity of areas in which future research is needed. Because evaluation is at the heart of decision making about diagnosis and treatment, we need to identify optimal methods for assessment and assure that they are free of systematic biases. We need additional studies of novel interventions but also studies to help us determine which of our available treatments are more or less likely to work for an individual patient so that we can develop personalized treatment strategies. We also need a greater focus on patient samples, including patients with comorbidities, that are similar to clinical practice as well as examination of global outcomes such as functioning and quality of life in addition to symptoms. Study designs should also use consistent methods and ratings so that data can be compared across different studies. Finally, we need more health systems and implementation research to assure that evidence-based treatments are delivered effectively and equitably.
Laura J. Fochtmann, MD, MBI, is a Distinguished Service Professor of Psychiatry, Pharmacological Sciences and Biomedical Informatics at Stony Brook University in New York. Since 2001, Dr. Fochtmann has also served as the Medical Editor for the American Psychiatric Association Practice Guidelines. She has extensive experience in caring for patients with acute psychiatric illnesses and has received multiple awards for teaching of residents and medical students. She has had a major role in adapting the Stony Brook University Hospital electronic record system to meet the needs of the psychiatric services. In addition, Dr. Fochtmann’s funded research and publications have spanned a broad range of topics including neurochemical effects of psychiatric treatments in animal models, psychiatric epidemiology, and approaches such as practice guidelines to enhance the quality of psychiatric care.