Pharmacological guidelines for schizophrenia: a systematic review and comparison of recommendations for the first episode

Abstract

ObjectivesClinical practice guidelines (CPGs) support the translation of research evidence into clinical practice. Key health questions in CPGs ensure that recommendations will be applicable to the clinical context in which the guideline is used. The objectives of this study were to identify CPGs for the pharmacological treatment of first-episode schizophrenia; assess the quality of these guidelines using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument; and compare recommendations in relation to the key health questions that are relevant to the pharmacological treatment of first-episode schizophrenia.MethodsA multidisciplinary group identified key health questions that are relevant to the pharmacological treatment of first-episode schizophrenia. The MEDLINE and EMBASE databases, websites of professional organisations and international guideline repositories, were searched for CPGs that met the inclusion criteria. The AGREE II instrument was applied by three raters and data were extracted from the guidelines in relation to the key health questions.ResultsIn total, 3299 records were screened. 10 guidelines met the inclusion criteria. 3 guidelines scored well across all domains. Recommendations varied in specificity. Side effect concerns, rather than comparative efficacy benefits, were a key consideration in antipsychotic choice. Antipsychotic medication is recommended for maintenance of remission following a first episode of schizophrenia but there is a paucity of evidence to guide duration of treatment. Clozapine is universally regarded as the medication of choice for treatment resistance. There is less evidence to guide care for those who do not respond to clozapine.ConclusionsAn individual's experience of using antipsychotic medication for the initial treatment of first-episode schizophrenia may have implications for future engagement, adherence and outcome. While guidelines of good quality exist to assist in medicines optimisation, the evidence base required to answer key health questions relevant to the pharmacological treatment of first-episode schizophrenia is limited.

PROFIP: A Portuguese early intervention programme for first‐episode psychosis in Lisbon

“…Standard care for first-episode psychosis includes acute inpatient care and psychiatric outpatient clinic follow-up, with no assertive practices, psychoeducation, family intervention or cognitivebehavioural therapy for psychosis. There are about 10 teams in Portugal, mainly in the north and centre of the country, providing early detection, treatment and support to young people with psychosis according to international guidelines (International Early Psychosis Association Writing Group, 2005;Keating et al, 2017). Some of these teams also give care to individuals in the at-risk stage for psychotic disorders (at-risk of mental state) before the development of fullblown psychotic episode (Yung et al, 2005;Yung & Nelson, 2011 A significant proportion of patients presenting with FEP have an unclear clinical picture with different degrees of mood and psychotic symptoms.…”

Chronic low-grade peripheral inflammation is associated with ultra resistant schizophrenia. Results from the FACE-SZ cohort

“…Clozapine is still considered to date as the most effective antipsychotic (Sultan et al, 2017) and a meta-analysis confirmed the largest effect size among the newer generation antipsychotics . Since the pivotal study by Kane et al (Kane et al, 1988) found that about a third of stringently defined treatment-resistant patients responded to clozapine, it has been the gold standard medication in this specific population and is now recommended in international therapeutic guidelines (Abidi et al, 2017;Hasan et al, 2015Hasan et al, , 2013Howes et al, 2017b;Keating et al, 2017;Leucht et al, 2015;Lo et al, 2016;Remington et al, 2017;Samalin et al, 2013;Stahl et al, 2013). However, 40% still remain classified as resistant to clozapine, which has been called "ultra resistance to treatment in schizophrenia" (UTRS) (Siskind et al, 2017).…”

Improvement of psychiatrists’ clinical knowledge of the treatment guidelines for schizophrenia and major depressive disorders using the ‘Effectiveness of Guidelines for Dissemination and Education in Psychiatric Treatment (EGUIDE)’ project: A nationwide dissemination, education, and evaluation study

“…Various guidelines have been published for the treatment of psychiatric disorders. [1][2][3][4][5][6][7][8] In many countries, psychiatrists usually treat patients based on treatment guidelines. However, evidence-based treatment guidelines for psychiatric disorders were not developed in Japan until 10 years ago; as a result, Japanese psychiatrists were likely to base clinical decisions on their own experiences.…”