The Psychopharmacology Algorithm Project at the Harvard South Shore Program

Abstract

This article is an update of the algorithm for schizophrenia from the Psychopharmacology Algorithm Project at the Harvard South Shore Program. A literature review was conducted focusing on new data since the last published version (1999-2001). The first-line treatment recommendation for new-onset schizophrenia is with amisulpride, aripiprazole, risperidone, or ziprasidone for four to six weeks. In some settings the trial could be shorter, considering that evidence of clear improvement with antipsychotics usually occurs within the first two weeks. If the trial of the first antipsychotic cannot be completed due to intolerance, try another until one of the four is tolerated and given an adequate trial. There should be evidence of bioavailability. If the response to this adequate trial is unsatisfactory, try a second monotherapy. If the response to this second adequate trial is also unsatisfactory, and if at least one of the first two trials was with risperidone, olanzapine, or a first-generation (typical) antipsychotic, then clozapine is recommended for the third trial. If neither trial was with any these three options, a third trial prior to clozapine should occur, using one of those three. If the response to monotherapy with clozapine (with dose adjusted by using plasma levels) is unsatisfactory, consider adding risperidone, lamotrigine, or ECT. Beyond that point, there is little solid evidence to support further psychopharmacological treatment choices, though we do review possible options.

Efficacy and safety of aripiprazole augmentation of clozapine in schizophrenia: A systematic review and meta-analysis of randomized-controlled trials

“…Together with other antipsychotic agents, aripiprazole is a firstline treatment for schizophrenia (Osser et al, 2013). It differs from others by stabilizing dopamine function through dopamine D2 receptor partial agonism, not D 2 antagonism (Croxtall, 2012).…”

The Psychopharmacology Algorithm Project at the Harvard South Shore Program

“…[2][3][4][5][6] In brief, the authors reviewed other algorithms and guidelines on bipolar mania and conducted literature searches using PubMed with keywords such as mania, algorithm, management, and psychopharmacology, focusing on new randomized, controlled trials (RCTs) not considered in previous reviews, in an attempt to survey the entire body of evidence. In constructing the decision tree, the authors gave preference in the early nodes to treatments that are effective for the current mania episode but that also may prevent subsequent depressive episodes.…”

“…59 Many guidelines and algorithms for treating schizophrenia, including the PAPHSS algorithm, do not find olanzapine appropriate for first-line use in that disorder. 3 In mania, the Texas Medication Algorithm Project separated olanzapine from the first-line options for all mania patients (euphoric and mixed). 60 The World Federation of Societies of Biological Psychiatry guidelines declared in 2009 that olanzapine is "not to be used first" in mania, because of the risks.…”

The psychopharmacology algorithm project at the harvard south shore program: 2012 update on psychotic depression

“…This algorithm update is one of several recently published by the PAPHSS (1,(8)(9)(10)(11) and available in condensed format for access on smart phone devices on the website www.psychopharm.mobi. The methods of producing these algorithms have been described in the previous publications.…”