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Mental Health Matters Journal for Psychiatrists & GP's

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Deborah Brauser
May 16, 2013

A team of schizophrenia experts have joined together to release worldwide "meta-guidelines" for physicians, nurses, and other healthcare professionals in managing and treating patients with the disorder.

The new guidelines, which, among other clinical issues, cover brain imaging and electroconvulsive therapy (ECT), are designed to provide "the most evidence-based and up-to-date strategies for addressing treatment selection, medication-induced side effects, [and] treatment nonadherence."

"We're trying to provide a service to people who are trying to reconcile different and possibly competing guidelines," guideline author Stephen M. Stahl, MD, PhD, adjunct professor of psychiatry at the University of California, San Diego, told Medscape Medical News.

"So rather than saying we're creating all new guidelines that will take over, this is more of a communications exercise that's making it easier and giving 'one-stop-shopping' of what's out there," said Dr. Stahl, who is also from the Neuroscience Education Institute (NEI) in Carlsbad, California, and is editor-in-chief of CNS Spectrums, the journal of the NEI.

He added that previously, there has been no definitive set of guidelines to help clinicians judge what a patient with schizophrenia needs at each stage of their illness. Their meta-guidelines, or "guideline of guidelines," brings together existing standards and updates them with current best practices.

"We are confident they will benefit anyone working in the field anywhere across the world," said Dr. Stahl in a release.

Dr. Stephen Stahl

The investigators note that the guidelines are aimed toward "rank-and-file patients with schizophrenia" who are neither violent nor self-harming and who do not have any comorbidities. A set of meta-guidelines for treating more complex cases is currently being developed by the same investigative team.

The new guidelines were published online April 16 in CNS Spectrums.

Clearing the Confusion

"Guidelines for treating various conditions can be helpful in setting practice standards," write the researchers.

However, "what has been available is a confusing mix of several sets of guidelines from different countries, experts, and settings. Often these recommendations contradict one another and are quickly out of date," said Dr. Stahl.

He and 8 other clinicians from California, New York, Texas, and the United Kingdom came together to provide schizophrenia guidelines that would combine the best of current standards while also providing updated information about the use of newer agents — several of which came out after the publication of current practice guidelines.

They collected both published and unpublished recommendations on treating acute and maintenance phases of the disorder from many sources, including the American Psychiatric Association (APA), the Texas Medication Algorithm Project, the Patient Outcomes Research Team, and state and federal hospitals — and then worked toward reconciling all the differences.

"Although clinical judgement must be exercised in the care of individual patients, these meta-guidelines may serve to assist clinicians [in addressing] issues commonly encountered in treating patients with schizophrenia," write the investigators.

Advice from the opening "overview" section includes the advice that other psychiatric disorders should be considered, that a therapeutic alliance should be formed, that patients should be reassessed frequently, and that comorbid conditions such as substance abuse should be monitored for and treated in collaboration with others.


In addition, the guidelines note that low doses of atypical antipsychotics should be used to initiate treatment during first-episode illness; only if unsuccessful should conventional antipsychotics then be used; and clinicians should "strongly consider clozapine after two unsuccessful antipsychotic trials."

It then provides 10 pages of detailed bullet points for assessments (including physical and laboratory tests for monitoring vital signs, body weight, and possible treatment-induced side effects), treatment in the inpatient and outpatient setting, and how to formulate and implement a treatment plan at each stage of illness, including the possibility of psychosocial interventions or ECT during the stable phase.

Key points on various medications are also presented in detail.

"The hope was to translate, not invent, and to communicate with visually interesting and easy-to-follow things for busy clinicians," said Dr. Stahl. "I think sometimes guidelines are written more for journals or academics. We wanted something that was aimed at practitioners and that was user-friendly."

The investigators note that they are now working on a new set of meta-guidelines "for more complex, yet commonly encountered patients with schizophrenia for use and guidance for what to do when the meta-guidelines provided here fail to provide adequate outcomes."

"The issue is: what do you do when these guidelines end and the patient still hasn't responded? And the problem is that there isn't a lot of evidence for what's next, not a lot of randomized, controlled trials. So the next stage will be put together with more expert consensus and cases," added Dr. Stahl.

Critical Synethesis

"I thought these guidelines were a very thoughtful attempt to critically synthesize the best information from experts around the world into helpful suggestions for treatment," Ira D. Glick, MD, professor emeritus in the Department of Psychiatry at the Stanford University School of Medicine, in California, told Medscape Medical News.

Dr. Ira Glick

"Clinicians now have a synthesis of what world leaders think based on evidence-based data. And that's a big help," he said. Dr. Glick, who is also the former director of the Schizophrenia Clinic at Stanford Medical Center, was not involved with this research.

When asked whether he thinks these new meta-guidelines could take the place of stand-alone guidelines from other organizations, Dr. Glick said that that is possible.

"For some people, this could take the place. But for different countries, factors affecting treatment vary. So there will always be individualized treatment based not only on the patient (and their family) but also on the village, country, region, etc, where they're being treated," he said.

What about for clinicians in the United States? Should this take the place of schizophrenia guidelines from the APA?

"I think both are helpful. Just as there are many textbooks in psychiatry that suggest what to do and clinicians pick the top 2 or 3, there's always a choice. Some people will want to follow the APA guidelines because it has the APA imprimatur. Others might say that these have something to add. So I think it'll vary from clinician to clinician," replied Dr. Glick.

"I do feel that this is a nice contribution to the literature. What all of us try to do is not just rely on our clinical experience. We try to look at the evidence-based data, then put that together with what's in the journals and texts and what we learn in CME courses, and then try to factor all that into our individual experiences. So I think this will be very helpful, and I'm appreciative of the effort that went into it."

The study authors report several relevant financial relationships, which are provided in the original article.

CMS Spectr. Published online April 16, 2013.


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