Schizophrenia Treatment Recommendations Updated

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The new PORT guidelines focus on improving physical as well as mental health.

The Schizophrenia Patient Outcomes Research Team (PORT) has issued updated treatment recommendations that not only include detailed advice about medication and psychosocial treatments but also address, for the first time, common problems in this population such as smoking cessation, substance abuse treatment, and weight loss. The authors note that the goal is not only to help clinicians and patients understand how to increase chances of schizophrenia recovery (albeit modest in scope), but also how to reduce the risk of additional life-threatening medical problems such as diabetes and cardiovascular disease.

The PORT recommendations, issued in 1998 and first updated in 2003, were funded by the Agency for Healthcare Research and Quality and the National Institute of Mental Health. Researchers at the University of Maryland wrote the latest update after consulting with leading schizophrenia experts. In contrast to efforts like the American Psychiatric Association practice guidelines for schizophrenia and the Texas Medication Algorithm Project, which attempt to address the full range of situations clinicians encounter, the PORT review is more conservative in scope. The PORT authors limit their recommendations to those interventions that have been tested in randomized controlled trials.

Medication Advice

Since the last PORT review, two large clinical trials have compared efficacy of first- and second-generation antipsychotics: the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) and the Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS). Based on the findings of these studies, the PORT reviewers noted that in many cases, first- and second-generation antipsychotics are equally effective for treating schizophrenia.

First-episode psychosis. The PORT review recommends using any antipsychotic except clozapine (Clozaril) and olanzapine (Zyprexa), because these drugs are most likely to cause significant weight gain and other metabolic side effects. Because patients experiencing psychosis for the first time are both more responsive to medications and more likely to have side effects, antipsychotics should be prescribed at doses that are lower — generally about half — compared with those recommended for patients with chronic schizophrenia.

Relapse. Patients who initially responded to medication but suffer a relapse of symptoms have several options. The PORT team recommends any first- or second-generation antipsychotic other than clozapine, and stipulates that medication be prescribed at the lowest effective doses to reduce side effects. Choice of which antipsychotic to use depends on patient preference, past medication response, side effects, and medical history.

Maintenance therapy. Studies that have followed patients with first-episode or chronic schizophrenia for one to two years have concluded that continuous maintenance antipsychotic treatment reduces risk of relapse. The PORT review recommends that intermittent maintenance therapy — a strategy of stopping antipsychotics until symptoms reappear or worsen — be reserved only for patients who refuse to continue taking an antipsychotic or for those who cannot tolerate the side effects.

For patients with chronic schizophrenia, both first- and second-generation antipsychotics are equally effective at preventing relapse. During maintenance therapy, first-generation drugs may be used at lower doses than those required to treat the initial (acute) episode, while second-generation drugs can be prescribed at whatever dose was effective in the initial phase.

Long-acting injectable antipsychotics provide another option in maintenance therapy, especially for patients who have trouble taking medication. The PORT review concluded that it is unclear whether injectable medications are any more effective than pills at preventing relapse, mainly because of a lack of randomized controlled studies.

Reference: Mental Health and Behavior section on Better Medicine

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