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Schizophrenia Clinical Practice Guidelines Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders Cherrie Galletly1,2,3, David Castle4, Frances Dark5, Verity Humberstone6, Assen Jablensky7, Eóin Killackey8,9, Jayashri Kulkarni10,11, Patrick McGorry8,9,12, Olav Nielssen13 and Nga Tran14,15 Abstract Objectives: This guideline provides recommendations for the clinical management of schizophrenia and related disorders for health professionals working in Australia and New Zealand. It aims to encourage all clinicians to adopt best practice principles. The recommendations represent the consensus of a group of Australian and New Zealand experts in the management of schizophrenia and related disorders. This guideline includes the management of ultra-high risk syndromes, first-episode psychoses and prolonged psychoses, including psychoses associated with substance use. It takes a holistic approach, addressing all aspects of the care of people with schizophrenia and related disorders, not only correct diagnosis and symptom relief but also optimal recovery of social function. Methods: The writing group planned the scope and individual members drafted sections according to their area of interest and expertise, with reference to existing systematic reviews and informal literature reviews undertaken for this guideline. In addition, experts in specific areas contributed to the relevant sections. All members of the writing group reviewed the entire document. The writing group also considered relevant international clinical practice 1Discipline of Psychiatry, School of Medicine, The University of Adelaide, SA, Australia 2Ramsay Health Care (SA) Mental Health, Adelaide, SA, Australia 3Northern Adelaide Local Health Network, Adelaide, SA, Australia 4Department of Psychiatry, St Vincent’s Health and The University of Melbourne, Melbourne, VIC, Australia 5Rehabilitation Services, Metro South Mental Health Service, Brisbane, QLD, Australia 6Mental Health and Addiction Services, Northland District Health Board, Whangarei, New Zealand 7Centre for Clinical Research in Neuropsychiatry, School of Psychiatry and Clinical Neurosciences, The University of Western Australia (UWA), Crawley, WA, Australia 8Orygen – The National Centre of Excellence in Youth Mental Health, Parkville, VIC, Australia 9The University of Melbourne, Melbourne, VIC, Australia 10The Alfred Hospital and Monash University, Clayton, VIC, Australia 11Monash Alfred Psychiatry Research Centre, Melbourne, VIC, Australia 12Board of the National Youth Mental Health Foundation (headspace), Parkville, VIC, Australia 13Psychiatry, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia 14St Vincent’s Mental Health, Melbourne, VIC, Australia 15Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia Corresponding author: Cherrie Galletly, The Adelaide Clinic, 33 Park Terrace, Gilberton, SA 5081, Australia. Email: [email protected] First published in Australian and New Zealand Journal of Psychiatry 2016, Vol. 50(5) 1-117. 2 guidelines. Evidence-based recommendations were formulated when the writing group judged that there was sufficient evidence on a topic. Where evidence was weak or lacking, consensus-based recommendations were formulated. Consensus-based recommendations are based on the consensus of a group of experts in the field and are informed by their agreement as a group, according to their collective clinical and research knowledge and experience. Key considerations were selected and reviewed by the writing group. To encourage wide community participation, the Royal Australian and New Zealand College of Psychiatrists invited review by its committees and members, an expert advisory committee and key stakeholders including professional bodies and special interest groups. Results: The clinical practice guideline for the management of schizophrenia and related disorders reflects an increasing emphasis on early intervention, physical health, psychosocial treatments, cultural considerations and improving vocational outcomes. The guideline uses a clinical staging model as a framework for recommendations regarding assessment, treatment and ongoing care. This guideline also refers its readers to selected published guidelines or statements directly relevant to Australian and New Zealand practice. Conclusions: This clinical practice guideline for the management of schizophrenia and related disorders aims to improve care for people with these disorders living in Australia and New Zealand. It advocates a respectful, collaborative approach; optimal evidence-based treatment; and consideration of the specific needs of those in adverse circumstances or facing additional challenges. Keywords Schizophrenia, schizoaffective, first-episode psychosis, management, treatment Off-label prescribing In this guideline, evidence and expert opinion for the effectiveness of treatments for schizophrenia and related disorders have been reviewed and considered. In some instances, the therapies (e.g. medicines) identified as effective may not be specifically approved for such use in Australia and/or New Zealand. The use of such therapeutic agents outside their approved indication(s) is sometimes referred to as ‘off-label’ use, and in practice, this may impact eligibility for third-party payer subsidy. We recommend careful documentation supporting your clinical use of specific therapeutic agents over alternatives that are approved in your country. It is also recommended that this issue is explained to patients, including informing them that they may personally have to meet added costs due to lack of third-party payer subsidy. Introduction This clinical practice guideline (CPG) was developed on behalf of the Royal Australian and New Zealand College of Psychiatrists (RANZCP). It updates the previous RANZCP CPG for the management of schizophrenia and related disorders (McGorry et al., 2005). It takes into account the findings of new research published since the previous edition and reflects an First published in Australian and New Zealand Journal of Psychiatry 2016, Vol. 50(5) 1-117. 3 increasing emphasis on early intervention, physical health, psychosocial treatments and improving vocational outcomes. It is important to acknowledge the extraordinary courage and perseverance shown by many people with schizophrenia, who often live with the burdens of symptoms, stigma, social exclusion and socioeconomic disadvantage. Their families and carers also face significant ongoing challenges. Scope and purpose This guideline provides recommendations for the clinical management of schizophrenia and related disorders for health professionals working in Australia and New Zealand. It aims to encourage all clinicians to adopt best practice principles. The recommendations represent the consensus of a group of Australian and New Zealand experts in the management of schizophrenia and related disorders. It is intended mainly for psychiatrists, psychiatry trainees, resident medical officers and hospital interns in psychiatry. It may also be useful to general practitioners (GPs), mental health nurses, other clinicians who work with people with schizophrenia and related psychoses, and policy makers. It does not override the responsibility of clinicians to make appropriate decisions, taking into account the unique circumstances of the person they are treating. The scope of this guideline is the schizophrenia spectrum which includes schizophrenia, schizoaffective disorder, schizotypal disorder, schizophreniform disorder and acute transient psychotic disorder with symptoms of schizophrenia. The spectrum notion is based on the presumption (and partial evidence) of a shared genetic background. Notably, persistent delusional disorder is not part of the spectrum. This guideline includes the management of ultra-high risk syndromes, first-episode psychoses (FEPs) and prolonged psychoses, including psychoses associated with substance use. Childhood onset schizophrenia, a very rare condition requiring specialist management, is not included. The prescription of antipsychotic drugs for conditions other than schizophrenia and related disorders is also beyond the scope of this CPG. Psychoses associated with affective disorders are covered in the RANZCP CPG on mood disorders (Malhi et al., 2015). This CPG does not include detailed information about mental state examination, diagnostic criteria and differential diagnosis – these matters are covered in textbooks and manuals of diagnostic criteria. Method Developing the recommendations and commentary. The working group planned the scope and individual members drafted sections according to their area of interest and expertise, with reference to existing research literature and reviews. In addition, experts in specific areas contributed to the relevant sections. The working group considered recent international CPGs, including the UK National Institute for Health and Care Excellence (NICE) (2014) clinical guideline on the treatment and management of psychosis and schizophrenia in adults and the World Federation of Societies of Biological Psychiatry guidelines for the biological treatment of schizophrenia (Hasan et al., 2012, 2013, 2015; Thibaut et al., 2015). The staging model (McGorry et al., 2006) provided a framework for assessment and clinical management and for the choice and timing of interventions. First published in Australian and New Zealand Journal of Psychiatry 2016, Vol. 50(5) 1-117. 4 For intervention
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