Clinical Practice Guidelines for Management of Schizophrenia

Participants of expert group on CPG for Schizophrenia B.N. Gangadhar, P.K. Dalal, Lalit Batra, Kishore Gujar, O.P Singh, Bharat Singh, Abhay Matkar, Devendra Vijayvargiya, R.K. Solanki, Adarsh Tripathi INTRODUCTION Schizophrenia is a serious mental disorder with prevalence rates of 2-3 per 1000 reported from India. The impact of schizophrenia on patients, their families and the wider society are no different from what has been observed in the rest of the world. However, resource constraints, poverty, lack of education and inadequate access to health care facilities for patients make the problem of providing care particularly daunting in India. In 2005, the Indian Psychiatric Society came up with treatment guidelines for schizophrenia tailored to meet the requirements of our patients in the context of prevailing existing resources. There have been several developments in the management of schizophrenia since then. These new set of guidelines attempt to update the previous guidelines by emphasizing what is new in the field. These guidelines ought to be read in conjunction with the earlier version of the treatment guidelines on schizophrenia as developed and published by the Indian Psychiatric Society in the year 2005. SCOPE OF THIS DOCUMENT The major emphasis of the current guidelines is on areas in the management of schizophrenia, which have witnessed significant developments since the publication of the previous guidelines. These guidelines are not particularly applicable to any specific treatment setting and may need minor modifications to suit the needs of patients in a specific setting. The recommendations are primarily meant for adult patients. The needs of children or the elderly with schizophrenia may be different. Finally, it is expected that recommendations made will have to be tailored to suit the needs of individual patients. Assessment and evaluation (table-1)Table 1: Components of assessment and evaluationA comprehensive assessment of the patient and his/her caregivers needs to be carried out. The cornerstone of this assessment is a detailed history and physical and mental state examinations. Efforts should be made to obtain information from all sources, especially the family. Wherever possible, diagnosis of schizophrenia be preferably made according to current diagnostic criteria, as such a diagnosis is more reliable. A reliable diagnosis facilitates communication among clinicians, and allows for better applicability of evidence-based recommendations. Many clinical conditions that may mimic schizophrenia include mood disorders, substance-induced psychoses and psychoses secondary to physical illnesses. These should be ruled out as far as possible by history, examination and additional investigations. In some instances a definitive diagnosis may need time. Further, because of the enormous psychosocial consequences a diagnosis of schizophrenia needs to be made with great caution and sensitivity. In doubtful cases, a medication-free observation period can be considered. However, consideration of medication free period need to be balanced against the risks of delaying treatment or the potential for harm to self and others in acutely ill patients. It is important to remember that diagnosis is not a one-time affair, but a continuous process. Accordingly, based on the subsequent information from patients and caregivers, and on repeated clinical evaluations the diagnosis may need re-evaluation. The assessment should cover all other areas such as symptom dimensions, symptom-severity, comorbid psychiatric and medical conditions, particularly comorbid substance abuse, the risk of harm to self or others, level of functioning and the socio-cultural milieu of the patient. A high index of suspicion along with thorough assessment can help in detecting most patients with comorbid substance abuse/dependence. Wherever, facilities are available, urine or blood screens (with prior consent) can be used to confirm the presence of comorbid substance abuse/dependence. A thorough physical examination need to be done to rule out presence of any physical illness and also to rule out psychoses secondary to physical illnesses. This may be supplemented by the judicious use of investigations. Wherever possible, unstructured assessments need to be supplemented by ratings on appropriate standardized rating scales. Other options such as detailed cognitive testing can be done if required and feasible. The use of neuroimaging may be indicated in those with first-episode psychosis, neurological signs, non-response to treatment and elderly patients. Assessments of caregivers may focus on areas such as their knowledge and understanding of the illness, their attitudes and beliefs regarding treatment, the impact of the illness on them and their personal and social resources. It is important to remember that assessment is an ongoing process. As the treatment progresses other areas such as response to treatment, side effects, treatment adherence, the impact of patient's immediate environment, disability assessments, other health-care needs, ease of access and relationship with the treatment team may need to be assessed separately. Formulating a treatment plan (figure 1)Figure 1: Initial evaluation and management plan for schizophreniaFormulation of treatment plan involves deciding about treatment setting, treatments to be used and areas to be addressed. Patients, caregivers and staff involved in care may be consulted while preparing the treatment plan. Treatment plans be needs-based, practical, feasible and flexible. These should be continuously re-evaluated and modified as required. Choice of treatment settings The basic principle while choosing a treatment-setting is to provide care in the least restrictive setting, which nevertheless meets the needs of patients and caregivers. The commonest treatment settings would be either outpatient clinics or inpatient wards. In some instances resources for long-term inpatient care, or community or residential care may be available. The bulk of the patients would probably receive treatment in outpatient settings. Given their severe shortage, inpatient beds are likely to be scarce. Common indications for inpatient care during acute episodes are shown in table-2. Whenever possible patient admitted to the inpatient setting should have accompanying family caregivers. In case inpatient care facilities are not available, than the patient and/or family need to be informed about such a need and admission in nearest available inpatient facility may be facilitated.Table 2: Some indications for inpatient care during acute episodesOptions for management for schizophrenia Treatment options for management of schizophrenia can be broadly classified as antipsychotic medications, electroconvulsive therapy (ECT), adjunctive medications and psychosocial interventions (table-3).Table 3: Options for management for schizophreniaPharmacological treatment Choice of antipsychotic medication The essential choice is between using an antipsychotic belonging to the class of typical antipsychotics (FGA-first-generation antipsychotic) or from the atypical group (SGA- second-generation antipsychotic). Since the publication of the previous guideline there is somewhat greater clarity on this matter. The bulk of the evidence including large-scale real-world studies indicates that there is very little difference in terms of efficacy, adherence and other subjective aspects between the FGA and the SGA group, or between individual antipsychotics belonging to either group. The only exception to this trend is clozapine, which appears to be more efficacious than any other antipsychotic in patients with treatment resistance. It follows from this that the choice of the antipsychotic will depend on factors other than efficacy. Some of these factors are included in table-4.Table 4: Factors that influence selection of antipsychoticsDose The recommended dose of various oral antipsychotics available in India is shown in table-5. In general patients with first-episode psychosis respond to lower doses. The use of high or very high doses (mega doses) of antipsychotics, if required, may be used with caution in exceptional circumstances. It is noted that Indian patients require lower doses of antipsychotic drugs compared to patients from the West. Although this is suggested by clinical experience and pharmacokinetic studies of Asian patients, there is little evidence for, or against this supposition from clinical trials.Table 5: Recommended therapeutic dose ranges for various antipsychoticsRoute of administration Acutely agitated patients often require parenteral administration of antipsychotics to rapidly control the behavioural disturbance. Liquid or mouth-dissolving formulations are often helpful in non-compliant patients. Depot preparations are generally not used in acutely agitated patients except zuclopenthixol acetate, which has a half-life of about 20 hours. In general, it is recommended that one drug is to be used by one route in order to minimise drug interactions and simplify clinical observations. Depot preparations (table-6) are often helpful in ensuring medication-compliance and may be used in situations where compliance is a problem. Depot injectables may also be used if patients/relatives indicate a preference for this kind of treatment. Test doses are administered at the start of treatment. When used, depot preparations need to be prescribed within the standard recommended dosage and interval range to achieve optimum effectiveness in preventing relapse.Table 6: Antipsychotic depot preparations available in IndiaAdequate antipsychotic trial The minimum recommended duration of treatment to consider it to be an effective trial for all antipsychotics is use of medication in the highest tolerable dose for 6-8 weeks, with the exception of clozapine, where the minimum period of treatment is at least 3-6 months. Response Antipsychotics are known to produce a significant remission of positive symptoms. This could thus be a reasonable of treatment during the acute Antipsychotics are effective in management of a to in is often Response for other aspects of the illness cognitive are not on antipsychotics need to be to the level of response and the of side 2: of patient with non-response to antipsychotic case a patient to respond to an antipsychotic compliance or need to be prior to the medication to a patient is to have compliance or to medications, all are to be made to the for lack of compliance and appropriate need to be to the problem. However, if a patient to respond to an trial of an antipsychotic medication dose for at least 6-8 with a in antipsychotic may be considered. need to be of of antipsychotics least one of which is a may also be earlier in patients are at risk for not to their current medication and those side with different of of antipsychotics There is evidence for the of of In the a may be to use a of antipsychotics to but caution need to be while These should be used on and for possible time. of antipsychotics for may be except in patients not to Although antipsychotic are the of treatment of schizophrenia, management may use of adjunctive treatments with mood or However, these can be used with and for possible assessment a evaluation need to be done for the of the and other mood can be prescribed in patients or those with to their current can be in and disturbance. may be of use in and may be the patient has symptoms. In general use of is not It is better to start these drugs the patient side Whenever are required, use may be to possible doses and for possible time. As in other is used in schizophrenia in India. The evidence for of in the acute of schizophrenia is somewhat There is evidence for and of is used in conjunction with antipsychotics in the acute but the of the of to antipsychotics is and the positive to only for the of treatment. However, there may be some in to the treatment in patients respond to The more indications for in with antipsychotics are included in is not in schizophrenia and there is not evidence to use in the except in exceptional circumstances. Finally, is used information and for patients and caregivers, informed administration and of response and side be indications of use of in patients of of may be for the patient and family The is to the patient and family about the and about the of the patient's illness, likely side effects, likely of treatment can be also need to be to the of the illness, and what it for the patient and the family as a It is important that are and but and thorough in their use of clinical and in the is to be to the family. Treatment adherence will be at this to of the previous may be and is to be tailored to the needs of the patient and the caregivers. interventions are to be an of management of psychosocial interventions including family cognitive behavioural social cognitive individual group case use of community and of have been to be in the management of The and of psychosocial treatments has probably not the it in the Indian there is Indian evidence and experience with family and other such as community and cognitive on these psychosocial from the to the can be recommended for patients with schizophrenia and their which the needs of patients and their families could be There has been a in India of families in the care of their with mental There are several studies the of family of treatments such as or unstructured and psychosocial treatments have been the of it appears that a range of interventions and from the to the may be in the Indian The basic emphasis need to be on and medication adherence while and A in which interventions are tailored to the and needs of the is more likely to their and influence the of families to in such the patients are to be for a in the and to the risk of side and and These include physical modifications and from to family need to be be and to the needs of patients and their However, family resources for more may not be available in and can a of the psychosocial A relationship between patients and in which a therapeutic is an essential of could include and and Efforts to may also be along with medication is the most treatment in and families individual as among the most to patients with Other interventions that are care, for caregivers, cognitive or and on the of these and their wider is of any psychosocial are in more specific recommendations other may be about psychosocial is as to which the in terms of medications, with the clinical in this context thus to a treatment of treatment, or of including those that to medication that about of the patients with schizophrenia not with the treatment about their with the and of patients out from treatment. Common factors with medication are shown in Factors to include or subjective response to comorbid substance abuse, and therapeutic need to make to the rates of medication compliance and treatment It is important for the to that the or patient factors and illness factors are for medication compliance and Some of the factors which may be in Indian context include communication between the and the therapeutic and need to focus on better communication and therapeutic with patient and the family to Whenever medication or treatment all need to be made to the the evaluation of need to cover assessment of and need to be by and of treatment. compliance can be by using depot preparations and use of formulations also of and Factors with medication OF of schizophrenia can be broadly acute treatment or or Some patients may very in a and appropriate for and management for this be required. It is known that of psychosis is often by and and These may the psychosis by to diagnostic the basic positive of risk with as as general that are not specific to also that patients with especially the high risk group have of to rates have been reported to range from Further, may have impact on the and cognitive more and more emphasis is on and Factors which have been shown to to psychosis include presence of risk with in of presence of social duration of high of and history of substance In terms of management of it is suggested that treatment ought to be based on the needs of the patient. There is some evidence to that use of antipsychotics in can the to psychosis and may be in in a of patients. However, at evidence for use of antipsychotics in is not to use in all patients. There is also evidence to the of In evidence that interventions cognitive cognitive psychosocial can functioning and during the the of these treatments are not Accordingly, a patient with of of schizophrenia, management is done in the of psychosocial of need to be against the side of antipsychotics and of in which can to psychosis or psychosis of antipsychotic OF patients in this are likely to such as or and behavioural functioning may be and can be at risk of or the patient and the family have in to terms with the of acute symptoms. The various aspects of management in the acute are included in in the acute This the acute in or and for about months. of this are shown in of in and of are the treatment during this of on the patient and the family by and and their to from the are other important of medication treatment, of response and side and psychosocial need to preferably at the dose for the months. The of psychosocial treatment are to treatment and adherence, for patients and their families and help the patient for in the psychosocial interventions may be at this Finally, of side and needs to in the treatment this of illness, are and severe than in the acute may and in social and functioning more or level of of and are the major of treatment during this of of this are shown in in the this can be 2-3 and more in of or if by the family. this of need to be from the family. new that are and some of the previous may need in the involves the The management plan should be for any need for It also involves the with antipsychotic medications and of side and the psychosocial In the management need to focus on personal of The of treatment during this are to or of and personal need to be are to be noted and the treatment As the of the illness, by the needs of the patient and the family and are all expected to and are to these assessment is thus It allows those modifications to be made in the treatment which are required to any new or that may have Assessments and is required for response and for side that may assessments may be required during this period especially if psychosocial treatments are should be from the patients, family and other available of will depend on several factors such as clinical the of the from the patient's social available for the the of treatment administered Antipsychotic treatment The dose of the antipsychotic needs to be A has to be between the need to side and the need to patients not have positive may be for in doses. need to be at the of about a minimum effective dose is of of antipsychotic medication may be be and for evidence of potential from antipsychotic for and of potential need to for at least the acute of is to be of of treatment on a of factors and will need to be The suggested guidelines are as patients ought to receive of treatment with several episodes or are to receive treatment for or the with history of or should receive treatment for period or The indications for use of or antipsychotic medications are shown in for use of antipsychotic interventions The psychosocial interventions in the previous treatment is to be and the should be Further, the should as to any is required in terms of and for are scarce. However, if the patient is can be made to help out in any at the which could be to the of the the patient is their for needs to be is for is to be to appropriate However, if the patient for that need to be in order to be for The management plan needs to be to respond as as possible to any in the patient's and need to be to of a need to be about the need for in of need to have access to treatment facilities such as or inpatient which will to the needs of a patient on the of a need to be during this such as or need to be feasible. these are important in and treatment of often clinical situations which either require or can influence treatment of these situations is in to Antipsychotics are with side effects, which require Some of the side that can be very to the patients include side effects, side effects, and side The side can be The management for these side are shown in of of side side are often noted in patients especially high antipsychotic However, is also with The acute include acute and is during the or of treatment, is dose and with of is use to of antipsychotics and these include and It is important to that is not on the dose of antipsychotics and the It is important to be of the risk factors for of these side factors for acute and side with case a patient is during the of treatment, the of management involves the dose of the antipsychotic in dose is with than of antipsychotic medication may be considered. When of antipsychotic medication is a medication with lower potential need to be In patients respond to an antipsychotic and to experience a of medications may be considered. is also during the of treatment, doses of respond to administration of parenteral or of acute can also be by using a of in management of acute involves in dose or the antipsychotic to a medication with lower Some patients may require the use of medications and or for management of It is an acute psychiatric which has been reported to more often with However, in the of case and case also of all with of factors which the risk of are shown in involves the antipsychotic and use of or of may also be helpful and those patients with respond to these may with of side with various antipsychotic Many antipsychotics are known to by of their and The risk of is high with and Initial should be to and and if this is not if possible dose be considered. and side These side as effects, and and Some patient may and to severe side side are more with and It is reported that the side are and with in the dose of antipsychotic or used side the side effects, the side include and interval of more than is with risk of known as which may to and the antipsychotics, and high dose of are reported to be with risk of the is reported to have risk of this has not been shown to be with In there is of antipsychotic is to be considered. with various antipsychotics is to It is with clozapine, the is often with can be by with lower doses and of When a patient with a antipsychotic the in management is to the dose of the this not help than to with lower is to be considered. management include use of the and use of which is a may be with or it may to to as with may be with dose and antipsychotics are shown to be with the rates with different In general, rates of are reported to be with and of the for with and is in which to of have been reported to be more to in management of and is in the dose of antipsychotic this is not in antipsychotic is to be considered. of antipsychotic is not possible, than management with or may be to lower the for side It is known that compared to in the general patients with schizophrenia have high rates of prevalence of that need to the patients for of side and the to the and Antipsychotics have also been shown to the risk of of evidence that there is some of various antipsychotic medications on and have been reported to be with highest risk for of and in blood the side with antipsychotics, various guidelines have been and there are in the In general it is suggested that patients need to be for at at and antipsychotic and or at least However, those have personal and family history of and/or are to be for while various antipsychotic in Indian setting, to rates and available it may not be feasible to all the Efforts need to be made to the and blood at treatment at and settings may consider of a patient of antipsychotic may be considered. In general if a patient more than of the or or any other significant or side a in antipsychotic is to be considered. However, while need to consideration the of the illness, comorbid physical side of medication which side and the potential side with medication to be used of antipsychotic is not possible medications or may be along with more and A need to be with and to provide care to patients.