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(WFSBP) Guidelines for Biological Treatment of Schizophrenia, Part 1: Update 2012 on the Acute Treatment of Schizophrenia and the Management of Treatment Resistance

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(WFSBP) Guidelines for Biological Treatment of Schizophrenia, Part 1: Update 2012 on the Acute Treatment of Schizophrenia and the Management of Treatment Resistance The World Journal of Biological Psychiatry, 2012; 13: 318–378 GUIDELINES World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia, Part 1: Update 2012 on the acute treatment of schizophrenia and the management of treatment resistance ALKOMIET HASAN 1 , PETER FALKAI1 , THOMAS WOBROCK 1 , JEFFREY LIEBERMAN 2 , BIRTE GLENTHOJ 3 , WAGNER F. GATTAZ 4 , FLORENCE THIBAUT 5 , HANS-J Ü RGEN MÖLLER 6 & THE WFSBP TASK FORCE ON TREATMENT GUIDELINES FOR SCHIZOPHRENIA ∗ 1 Department of Psychiatry and Psychotherapy, University of Goettingen, Goettingen, Germany, 2 Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York State Psychiatric Institute, Lieber Center for Schizophrenia Research, New York, NY, USA, 3 Center for Neuropsychiatric Schizophrenia Research & Center for Clinical Intervention and Neuropsychiatric Schizophrenia Research, Copenhagen University Hospital, Psychiatric Center Glostrup, Denmark, 4 Department of Psychiatry, University of Sao Paulo, Brazil, 5 University Hospital Ch. Nicolle, INSERM U 614, Rouen, France, and 6 Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University, Munich, Germany Abstract For personal use only. These updated guidelines are based on a fi rst edition of the World Federation of Societies of Biological Psychiatry Guide- lines for Biological Treatment of Schizophrenia published in 2005. For this 2012 revision, all available publications pertain- ing to the biological treatment of schizophrenia were reviewed systematically to allow for an evidence-based update. These guidelines provide evidence-based practice recommendations that are clinically and scientifi cally meaningful and these guidelines are intended to be used by all physicians diagnosing and treating people suffering from schizophrenia. Based on the fi rst version of these guidelines, a systematic review of the MEDLINE/PUBMED database and the Cochrane Library, in addition to data extraction from national treatment guidelines, has been performed for this update. The identifi ed lit- erature was evaluated with respect to the strength of evidence for its effi cacy and then categorised into six levels of evidence (A–F; Bandelow et al. 2008b, World J Biol Psychiatry 9:242). This fi rst part of the updated guidelines covers the general descriptions of antipsychotics and their side effects, the biological treatment of acute schizophrenia and the management of treatment-resistant schizophrenia. World J Biol Psychiatry Downloaded from informahealthcare.com by 82.113.121.223 on 07/27/12 Key words: Schizophrenia , antipsychotics , evidence-based guidelines , treatment , acute phase treatment , treatment resistance , biological treatment ∗ A. Carlo Altamura (Italy), Nancy Andreasen (USA), Thomas R.E. Barnes (UK), M. Emin Ceylan (Turkey), Jorge Ciprian Ollivier (Argentina), Timothy Crow (UK), Aysen Esen Danaci (Turkey), Anthony David (UK), Michael Davidson (Israel), Bill Deakin (UK), Helio Elkis (Brazil), Lars Farde (Sweden), Wolfgang Gaebel (Germany), Bernd Gallhofer (Germany), Jes Gerlach (Denmark), Steven Richard Hirsch (UK), Carlos Roberto Hojaij (Australia), Michael Hwang (USA), Hai Gwo Hwo (Taiwan), Assen Verniaminov Jablensky (Australia), Marek Jarema (Poland), John Kane (USA), Takuja Kojima (Japan), Veronica Larach (Chile), Jeffrey Lieberman (USA), Patrick McGorry (Australia), Herbert Meltzer (USA), Hans-Jürgen Möller (Germany), S. Mosolov (Russia), Driss Moussaoui (Marocco), Jean-Pierre Olié (France), Antonio Pacheco Palha (Portugal), Asli Sarandöl (Turkey), Mitsumoto Sato (Japan), Heinrich Sauer (Germany), Nina Schooler (USA), Bilgen Taneli (Turkey), Lars von Knorring (Sweden), Daniel Weinberger (USA), Shigeto Yamawaki (Japan). Correspondence: Dr.med. Alkomiet Hasan, MD, Department of Psychiatry and Psychotherapy, Georg August University Goettingen, Von- Siebold-Street 5, D-37075 Göttingen, Germany. Tel: ϩ 49 551 396610. Fax: ϩ 49 551 3922798. E-mail: [email protected] (Received 16 May 2012 ; accepted 18 May 2012 ) ISSN 1562-2975 print/ISSN 1814-1412 online © 2012 Informa Healthcare DOI: 10.3109/15622975.2012.696143 Biological treatment of schizophrenia: part one 319 Preface recommended to further strengthen the therapeutic effort. The goals and strategies of treatment vary In 2005, the World Federation of Societies of according to the phase and severity of illness. In the Biological Psychiatry (WFSBP) Guidelines for Bio- acute phase of treatment (lasting weeks to months), logical Treatment of Schizophrenia (Part 1: Acute which is defi ned by an acute psychotic episode, treatment of schizophrenia) were published. Since major goals are to develop an alliance with the patient 2005, new randomized clinical trials (RCT), open- and family, to prevent harm, control disturbed label trials and meta-analyses have been conducted behaviour, reduce the severity of psychosis and asso- and published, providing new evidence for the effi - ciated symptoms (e.g., agitation, aggression, negative cacy of biological treatment in schizophrenia. Knowl- symptoms, affective symptoms), determine and edge regarding the safety, tolerability and effi cacy of address the factors that led to the occurrence of the approved antipsychotic drugs has increased and new acute episode and to affect a rapid return to the best antipsychotic drugs have been introduced. Further- level of functioning. Special attention should be paid more, combination strategies and treatment with to the presence of suicidal ideation, intent or plan, therapeutic agents other than antipsychotics have and the presence of commanding hallucinations. The been further investigated and some new treatment patient should be informed about the nature and strategies have been developed. management of the illness, including the benefi ts Therefore, an update of the WFSBP Guidelines for and side effects of the medication, in a form that is Biological Treatment of Schizophrenia is imperative. appropriate to his or her ability to assimilate the information. In the acute treatment phase, the main emphasis is on pharmacotherapeutic (and other Executive summary of recommendations somatic) interventions. Therefore, antipsychotic therapy should be initiated as a necessary part of a General recommendations comprehensive package of care that addresses the This part remains partly unchanged and was adopted individual’s clinical, emotional and social needs. from the WFBSP 2005 guidelines and updated where necessary. Specifi c treatment is indicated for patients who meet diagnostic criteria for schizo- Specifi c treatment recommendations for the phrenia, a schizophrenic episode or psychotic symp- acute treatment of schizophrenia and the toms related to schizophrenic disorder (according to management of treatment resistance For personal use only. DSM-IV or ICD-10). An assessment of mental and physical health to evaluate relevant psychiatric and The separation into fi rst- and second-generation medical comorbid conditions, psychosocial circum- antipsychotics can be considered as arbitrary and stances and quality of life should be undertaken there is the need to choose the suitable drug for a regularly. When a person presents psychotic symp- certain clinical condition. However, to structure the toms for the fi rst time, a careful diagnostic evalua- text, especially with regard to the terms used tion should be performed, including laboratory in nearly all clinical trials, the terms FGAs and investigation and screening for drug abuse. Imaging SGAs are used, but the reader should be aware that techniques (preferentially MRI, if not accessible these terms represent rather a pseudo-classifi cation CCT), in order to exclude organic brain disease than a clinically and scientifi cally meaningful classifi cation. World J Biol Psychiatry Downloaded from informahealthcare.com by 82.113.121.223 on 07/27/12 should be performed when somatic disease is clini- cally suspected (e.g., encephalitis, see part 3 of these guidelines “Management of special circumstances First-episode schizophrenia and concomitant disorders”). However, CSF should only be investigated if an organic brain disease In fi rst-episode schizophrenia, antipsychotic phar- (e.g., encephalitis, immune mediated disease) is macological treatments should be introduced with expected. great care due to the higher risk of extrapyramidal After the initial assessment of the patient’s diag- symptoms (EPS). Appropriate strategies include nosis and establishment of a therapeutic alliance, a gradual introduction of antipsychotic medication treatment plan must be formulated and imple- with the lowest possible effective dose, combined mented. This formulation involves the selection of with careful explanation. The fi rst-line use of both the treatment modalities, the specifi c type(s) of treat- fi rst-generation (FGA) and second generation (SGA) ment, and the treatment setting(s). Periodic re- antipsychotic medication at the lower end of the evaluation of the diagnosis and the treatment plan standard dose range are possible treatments for a is essential. Engagement of the family and signifi - person experiencing a fi rst episode of schizophrenia. cant others, with the patient’s permission, is Antipsychotics should be chosen individually, 320 A. Hasan et al. respecting the patient’s mental and somatic condi- Treatment-resistant schizophrenia tion with special attention to side effects. However, Treatment-resistant schizophrenia can be defi ned as due to the reduced risk of inducing extrapyramidal a situation
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