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Guidelines for Biological Treatment of Schizophrenia, Part 1: Acute Treatment of Schizophrenia

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Guidelines for Biological Treatment of Schizophrenia, Part 1: Acute Treatment of Schizophrenia The World Journal of Biological Psychiatry, 2005; 6(3): 132Á/191 REVIEW World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia, Part 1: Acute treatment of schizophrenia PETER FALKAI1, THOMAS WOBROCK1, JEFFREY LIEBERMAN2, BIRTE GLENTHOJ3, WAGNER F. GATTAZ4, & HANS-JU¨ RGEN MO¨ LLER5, WFSBP Task Force on Treatment Guidelines for Schizophrenia* 1Department of Psychiatry and Psychotherapy, University of Saarland, Homburg/Saar, Germany, 2Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York State Psychiatric Institute, Lieber Center for Schizophrenia Research, New York, USA, 3Department of Psychiatry, University of Copenhagen, Bispebjerg Hospital, Denmark, 4Department of Psychiatry, University of Sao Paulo, Brazil, and 5Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University, Munich, Germany Abstract These guidelines for the biological treatment of schizophrenia were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal during the development of these guidelines was to review systematically all available evidence pertaining to the treatment of schizophrenia, and to reach a consensus on a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating people with schizophrenia. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for schizophrenia, as well as from meta-analyses, reviews and randomised clinical trials on the efficacy of pharmacological and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into four levels of evidence (AÁ/ D). This first part of the guidelines covers disease definition, classification, epidemiology and course of schizophrenia, as well as the management of the acute phase treatment. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication, other pharmacological treatment options, electroconvulsive therapy, adjunctive and novel therapeutic strategies) of adults suffering from schizophrenia. Key words: Schizophrenia, acute phase treatment, evidence-based medicine, practice guidelines, biological treatment, antipsychotics EXECUTIVE SUMMARY OF episode or psychotic symptoms related to schizo- RECOMMENDATIONS phrenic disorder. An assessment of mental and physical health to evaluate relevant psychiatric and medical comorbid conditions, psychosocial circum- General recommendations stances and quality of life should be undertaken Specific treatment is indicated for patients who meet regularly. When a person presents psychotic symp- diagnostic criteria for schizophrenia, a schizophrenic toms for the first time a careful diagnostic evaluation * A. Carlo Altamura (Italy), Nancy Andreasen (USA), Thomas R.E. Barnes (UK), Helmut Beckmann (Germany), Jorge Ciprian- Ollivier (Argentina), Tim Crow (UK), 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 R. Hojaij (Australia), Assen Jablensky (Australia), John Kane (USA), Takuja Kojima (Japan), Lars von Knorring (Sweden), Patrick McGorry (Australia), Herbert Meltzer (USA), Driss Moussaoui (Marokko), Franz Mu¨ller-Spahn (Switzerland), Jean-Pierre Olie (France), A. Pacheco Palha (Portugal), Mitsumoto Sato (Japan), Heinrich Sauer (Germany), Nina Schooler (USA), Daniel Weinberger (USA), Shigeto Yamawaki (Japan). Correspondence: Dr. med. Thomas Wobrock, M.D., Department of Psychiatry and Psychotherapy, University of Saarland, Kirrberger Strasse, D-66421 Homburg/Saar, Germany. Tel: /49 6841 1624216. Fax: /49 6841 1624270. E-mail: thomas.wobrock@uniklinik- saarland.de ISSN 1562-2975 print/ISSN 1814-1412 online # 2005 Taylor & Francis DOI: 10.1080/15622970510030090 WFSBP Guidelines for Biological Treatment of Schizophrenia 133 should be performed, including laboratory investiga- regular and liberal doses of benzodiazepines may be tion and imaging techniques (cerebral CT or MRI) essential to relieve distress, insomnia and beha- in order to exclude organic brain disease. After the vioural disturbances secondary to psychosis, while initial assessment of the patient’s diagnosis and antipsychotic medication takes effect. establishment of a therapeutic alliance, a treatment In multiple episodes the most common contributors plan must be formulated and implemented. This to symptom relapse are antipsychotic medication formulation involves the selection of the treatment non-adherence, substance use and stressful life modalities, the specific type(s) of treatment, and the events, although relapses are not uncommon as a treatment setting. Periodic reevaluation of the diag- result of the natural course of the illness, despite nosis and the treatment plan is essential. Engage- continuing treatment. If nonadherence is suspected, ment of the family and other significant support it is recommended that the reasons for it be persons, with the patient’s permission, is recom- evaluated and considered in the treatment plan. It mended to further strengthen the therapeutic effort. is recommended that pharmacological treatment The goals and strategies of treatment vary according should be initiated promptly, because acute psycho- to the phase and severity of illness. In the acute tic exacerbations are associated with emotional phase of treatment (lasting weeks to months), which distress, and a substantial risk of dangerous beha- is defined by an acute psychotic episode, major goals viours. Given the advantages of second-generation are to develop an alliance with the patient antipsychotics (SGAs), these antipsychotics gener- and family, to prevent harm, control disturbed ally seem preferable, although in principal all anti- behaviour, reduce the severity of psychosis and psychotics have their place in the treatment of acute associated symptoms (e.g., agitation, aggression, schizophrenia. The selection of an antipsychotic negative symptoms, affective symptoms), determine medication is guided by the patient’s previous and address the factors that led to the occurrence of experience of symptom response and side effects, the acute episode and to effect a rapid return to the intended route of administration, the patient’s pre- best level of functioning. Special attention should be ferences for a particular medication, the presence of paid to the presence of suicidal ideation, intent or comorbid medical conditions, and potential interac- plan, and the presence of command hallucinations. tions with other prescribed medications. The dose The patient should be provided with information on may be titrated as quickly as tolerated to the target the nature and management of the illness, including therapeutic dose of the antipsychotic medication the benefits and side effects of the medication, in a (e.g., 300Á/1000 chlorpromazine (CPZ) equivalents form that is appropriate to his or her ability to for FGAs) while monitoring the patient’s clinical assimilate the information. In the acute treatment status. Especially when using FGAs it is recom- phase, the main emphasis is on pharmacotherapeutic mended to keep the dose as low as possible to reduce (and other somatic) interventions. Therefore anti- the risk of extrapyramidal side effects. Rapid psychotic therapy should be initiated as a necessary dose escalation, high loading doses and treatment part of a comprehensive package of care that with high doses above the mentioned dose range addresses the individual’s clinical, emotional and do not have proven superior efficacy, but have social needs. been associated with increased side effects. For patients presenting with high degrees of agitation in an emergency setting there is evidence for Specific treatment recommendations superior efficacy with the combination of benzodia- In first-episode psychosis antipsychotic pharmacologi- zepines. cal treatments should be introduced with great care In assessing treatment-resistant schizophrenia (TRS) due to the higher risk of extrapyramidal symptoms or partial response, multidimensional evaluation (EPS). Appropriate strategies include gradual intro- should consider persistent positive or negative duction of low-dose antipsychotic medication with symptoms, cognitive dysfunction with severe impair- careful explanation. The first-line use of second- ment, bizarre behaviour, recurrent affective symp- generation antipsychotic medication (SGAs) (and toms, deficits in vocational and social functioning alternatively the use of first-generation antipsycho- and a poor quality of life. The target symptoms tics (FGAs) at the lower end of the standard dose should be precisely defined. It is important to range) is the preferred treatment for a person evaluate carefully whether there is insufficient im- experiencing a first episode of schizophrenia. This provement in the target symptoms, despite treat- recommendation is mainly based on the better ment at the recommended dosage for a duration of tolerability and reduced risk of tardive dyskinesia at least 6Á/8 weeks with at least two antipsychotics, associated with the
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