Treatment guidelines in schizophrenia

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Martin Lambert
MD

Dieter Naber
MD PhD
Professor
Department of Psychiatry and Psychotherapy
Centre for Psychosocial Medicine
University of Hamburg
Hamburg
Germany
E:[email protected]

Several treatment guidelines for schizophrenia have recently been published.(1-3) These guidelines include recommendations for acute as well as long-term pharmacological and psychosocial treatments. A problem associated with these guidelines is their applicability in everyday clinical practice. Therefore, many patients with schizophrenia, especially in the acute phase, are still not treated according to current research knowledge. This article attempts to adapt these guidelines for daily clinical practice. The following article is divided into:

• General principles of treatment.
• Acute pharmacological treatment in first- and multiple-episode schizophrenia.
• Treatment of psychiatric emergencies in schizophrenia.

Definitions
Acute treatment in schizophrenia is a complex approach of pharmacological and psychosocial interventions. Treatment can be hospital-based, but can also be administered outside the hospital if safety and intensive support standards are met. The main prerequisite for home-based treatment is a multiprofessional, flexible and easily accessible care team with sufficient experience in acute interventions and a risk profile that allows community-based crises intervention. The availability of an inpatient acute unit is also important, allowing a low threshold for hospital-based intervention.

Schizophrenia is a complex illness with a wide range of acute clinical presentations. For first-episode psychosis, the diagnosis is often difficult and unstable, and a dimensional approach is usually more adapted than a categorical one.(4) The primary goals of acute treatment in schizophrenia are to eliminate or reduce the positive or disorganised (psychotic) symptoms, to treat disturbed behaviour, such as agitation or hostility, and to reduce the risk of self-harm or harm to others. These goals should be addressed, whenever possible, without diminishing patients’ acceptability and engagement. The secondary goals of acute treatment are to prevent antipsychotic side-effects, to detect and possibly reduce negative or cognitive symptoms, to detect and treat comorbid disorders, such as depression or substance abuse disorders, and to implement psychosocial interventions to enhance patients and relatives’ understanding of the illness and the individual needs for  successful long-term treatment and rehabilitation.

General principles of treatment
The treatment of schizophrenia includes many different components that support each other in an integrated manner. Antipsychotic treatment is an important foundation, but not sufficient for successful acute treatment and relapse prevention if applied alone. An empirically proven principle of treatment is that concurrent treatment strategies of psycho-
therapy, such as cognitive behavioural therapy
(CBT), psychoeducation, family interventions, cognitive and social skills training, compliance therapy and vocational rehabilitation, can improve the prognosis significantly and also lead to better response to pharmacotherapy. These interventions should be incorporated in a long-term treatment programme. For people with schizophrenia, especially in the case of a first episode, several guidelines for delivery of care have to be addressed:

• Patients and their relatives seeking help should be assessed and receive treatment at the earliest possible opportunity.(1,2)
• The initial treatment is of major importance for engagement, understanding and patients’ acceptability, and professionals should take time to build a supportive and empathic relationship with patients and carers.(1,2,4)
• Professionals should work in partnership with patients and carers, offering help, treatment and care in an atmosphere of hope and optimism.(1)
• Professionals should make all efforts, such as giving adequate time for discussion and providing written information, to ensure that a patient can give meaningful and informed consent before treatment is initiated.(1-4)
• Professionals should provide information about schizophrenia and its treatment; this should be considered an essential part of routine treatment and management.(1-4)
• Assessment should address medical, social, psychological, occupational, economic, physical and cultural issues.(4,5)
• Risk assessment should include suicidal ideation and risk of self-harm, risk of violent or aggressive behaviour, risk-taking behaviour, nonadherence, risk for disengagement, comorbid depression and substance misuse.(4,5)

Acute pharmacological treatment
Several medical and pharmacological guidelines have to be addressed before and during acute
antipsychotic treatment:

• A medical assessment should be undertaken, possibly before initiating antipsychotic treatment.(1,2,4) Neuropsychological assessment should be completed after the acute phase.
• Wherever possible, patients should make an informed choice as to the antipsychotic they prefer. If a patient is unable to discuss preferences or is drug-naive, an atypical antipsychotic should be prescribed.(1,4)
• The choice of antipsychotic drug should be made jointly, based on an informed discussion of the benefits of the drugs and their side-effect profiles.(1,4)
• Atypical antipsychotics are the first-line treatment in first- and multiple-episode schizophrenia.(1–6)
• The minimum effective dose should be used. Low-dose treatment is at least as effective as higher doses in nonaffective first-episode psychosis.(4)
• Neuroleptic side-effects should be avoided to promote future medication adherence and engagement with treatment. Acute extrapyramidal side-effects (EPS), in particular, are related to various negative clinical consequences and reduced adherence.(4,5)
• A team consisting of a case manager and a physician should regularly monitor side-effects, response to medication and success of rehabilitation.(1–4)

Treatment of emergencies in schizophrenia
During acute episodes, some patients can become behaviourally disturbed and may need acute pharmacological and nondrug interventions to calm down. Behavioural emergencies are not rare events; approximately 8–10% of patients have to be actively restrained.(7) As a result, it is necessary to ensure that the environment is prepared and staff are well trained to assess and manage emergencies, including restraint, seclusion and risks- associated parenteral medication. The goal of emergency management is to assure safety for patients and staff and resolve the situation without harm and traumatic experiences.(7) The following guidelines have to be addressed:

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• Prevention is the key issue in emergencies in schizophrenia. This includes environmental issues (intensive care unit for prevention and treatment), staff issues (regular aggression management training), early detection and quality of interventions.
• Initial evaluation as early as possible, including vital signs, medical history, brief visual exam and brief psychiatric assessment (eg, primary psychiatric disturbance or intoxication).
• Before the start of pharmacological treatment, it is important to try nondrug interventions, such as avoidance of unprepared confrontations, identification and defusing of escalating tensions. In addition, the clinician should try to establish the patient’s concerns, reassure them and attempt to resolve conflict, offer reasonable options and encourage patients to check themselves into an intensive care area (or an equivalent), where the environment itself will not over- or understimulate them.

Before the start of (pharmacological) interventions, it is necessary to develop a “plan of care”,(7) including information about the patient’s medical history (such as drug allergies or causal medical aetiology). With regard to pharmacological interventions, the first step is to try oral benzodiazepines, such as lorazepam or diazepam, in combination with oral atypical antipsychotics, such as olanzapine as tablet or wafer, risperidone as syrup or quetiapine. For multiple- episode patients, oral conventional antipsychotics can also be used (eg, droperidol or haloperidol).

If the patient refuses medication, if this strategy does not lead to response or if the response needs to be rapid due to agitation or aggression, parenteral medication can be necessary. In these situations, it is important for all team members to have a clear communication and united attitude towards the necessity for parenteral medication, and to explain this to the patient calmly.

It should be considered that agitation usually results from psychotic anxiety and that interventions taken against the will of the patient can exacerbate this anxiety and lead to traumatisation. Therefore, such a decision should be taken after all alternatives have been considered and a psychiatrist has been consulted, if possible in the acute situation. For future discussions with the patient and for medicolegal reasons, the rationale and steps taken should be well documented.

Once the decision has been made, the team members should explain the necessity of the decision and what steps should be taken subsequently. Recommended preparations for use are:

• Lorazepam (if not available: clonazepam IM [intramuscular] or midazolam IM, with appropriate caution).
• Olanzapine IM.
• Ziprasidone IM. Despite its former popularity, haloperidol IM should be used with caution due to its safety profile. Diazepam IM should not be used, as its absorption is slow and erratic and may cause unpleasant local irritation. Chlorpromazine IM is also not recommended.

After parenteral medication, vital parameters should be monitored. Response to medication should be assessed after 15–30min. If response has not yet been fully achieved, the patient might subsequently be amenable to accepting oral benzodiazepines or an antipsychotic.

A well-established option to avoid repeated IM injections is the use of short-life depot medications (eg, zuclopenthixol acetate; Clopixel-Acuphase). In some patients, a disadvantage of this short-acting depot medication is the delayed onset of action (2–8h), although patients may respond after 30–45min. Zuclopenthixol acetate is effective for 24–36h; repeated zuclopenthixol injections within 24h of a previous dose are not required.

With reduction in the acuteness of the situation, growing awareness and traumatic reactions in patients, staff, family members or other caregivers make a “debriefing process” necessary. For all participants concerned, a clear explanation should be offered, in addition to the possibility of discussing their experiences. All emergency steps, including the debriefing process, should be documented.

Conclusion
Acute treatment is still the key intervention for successful long-term management of schizophrenia. The way this intervention is delivered is of major importance for patients. Atypical antipsychotics have become the most frequently used treatment in this phase, although many recommendations from recently published guidelines are still not daily clinical practice. Future efforts and resources are needed to transport current research knowledge into successful daily clinical acute intervention.

References

1. National Institute for Clinical Excellence (NICE). Schizophrenia. Core interventions in the treatment and management of schizophrenia in primary and secondary care. Clinical Guideline 1. London: National Collaborating Centre for Mental Health; 2002.
2. McGorry PD, Killackey E, Lambert M, et al. Summary Australian and New Zealand Clinical Practice Guidelines for the treatment of schizophrenia. Australas Psychiatry 2003;11:136-47.
3. Kane JM, Leucht S, Carpenter D, et al. Expert consensus guidelines series. Optimizing pharmacologic treatment of psychotic disorders. Introduction: methods, commentary, and summary. J Clin Psychiatry 2003;64 Suppl 12:5-19.
4. Lambert M, Conus P, Lambert T, et al. Pharmacotherapy of first-episode psychosis. Exp Opin Pharmacother 2003;4:717-50.
5. Naber D, Lambert M, Krausz M, et al. Atypical neuroleptics in the treatment of schizophrenic patients. 2nd ed. Bremen: UNI-MED Verlag AG; 2002.
6. Ehmann T, Hanson L. Early psychosis – a care guide. University of British Columbia; 2003.
7. Allen MH, Currier GW, Hughes DH, et al. The expert consensus panel for behavioural emergencies. The expert consensus guideline series: treatment of behavioural disorders. Postgrad Med 2001;Special report:1-88.