The new German evidence‐ and consensus‐based schizophrenia guideline

The German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) has just published its revised guideline on schizophrenia. For the first time, this is a living guideline, included in MAGICapp (Making GRADE the Irresistible Choice) ¹ , a digital browser‐based platform that allows to develop, publish and continuously update living guidelines.

Advantages of this platform include the consistency in evaluating evidence according to GRADE (Grading of Recommendations, Assessment, Development and Evaluation), the graphical depiction of the evidence, the possibility to develop shared decision‐making tools, and the chance to make all steps of guideline development transparent ² , ³ . We implemented a flexible evidence‐to‐decision framework focusing on the questions of interests, the quality of evidence, the risk‐benefit ratios, values and preferences of patients, resource consumption, feasibility and barriers to implementation, and possible inequalities within the health care system.

Among the 444 guidelines published in MAGICapp, this is the first one addressing schizophrenia. The guideline group included members of 41 professional associations (including two associations of people with lived experience), six experts, and the four authors of this report, who led the process. A comprehensive evaluation of financial and non‐financial conflicts of interests was performed, and they were rated by two independent experts. Delegates of the societies who had a conflict of interests for a given recommendation had to abstain from voting.

The transformation from a conventional to a digital living guideline was prepared from 2021 to 2023, funded by the German Federal Joint Committee ² . The revision process started in 2023. After two years, the new guideline, that from now on will be updated in a living cycle at least every year, was ready. It includes 154 recommendations for the diagnosis and treatment of schizophrenia and four general statements. The document is freely available on the website of the Association of the Scientific Medical Societies in Germany (www.awmf.org), as a long (in German) and short (in German and English) version, and as a living guideline in MAGICapp (https://app.magicapp.org/#/guideline/jlYvkL).

The structure of the guideline is based on the 2019 published version, with Module 1 (General principles of the management of schizophrenia); Module 2 (Diagnostics, including ICD‐11, and differential diagnoses, including autoimmune psychoses and rare diseases); Module 3 (Treatment in general); Module 4a (Pharmacotherapy, electroconvulsive therapy, transcranial magnetic stimulation, management of side effects); Module 4b (Psychotherapy and psychosocial care); Module 4c (Special circumstances, such as first episode, depression; post‐traumatic stress disorder, PTSD; catatonia, aggression, at‐risk stage, childhood and adolescence, the elderly, pregnancy and breast‐feeding, gender aspects); Module 4d (Medical, social and occupational interventions, such as supported education or employment and rehabilitation); Module 5 (System‐relevant interventions and integrated cooperation of all service providers); Module 6 (Cost‐effectiveness); and Module 7 (Quality management) ⁴ .

All recommendations of the 2019 published version were reviewed and updated, or replaced where necessary. As in 2019, the guideline recommends a comprehensive differential diagnostic process, and the monitoring and improvement of physical health of people with schizophrenia. Moreover, the guideline still highlights the combination of a continuous antipsychotic treatment with cognitive‐behavioral therapy (CBT) as the gold standard. The following recommendations, highlighted in our 2020 report in this journal ⁴ , remained unchanged or were adapted in some detail:

• to offer regular monitoring of physical health to all persons with schizophrenia;

• to evaluate and classify symptoms suggesting typical medical comorbidities in every patient with schizophrenia;

• to offer magnetic resonance imaging (MRI) to every person with first‐episode schizophrenia, and to consider cerebrospinal fluid investigations if the course of disorder, the symptomatic presentation, or MRI or laboratory measures point towards a secondary psychosis;

• to offer acute and maintenance antipsychotic drug treatment using the lowest possible dosage to every person with schizophrenia;

• to select an antipsychotic drug mainly based on the side effect profile;

• to work out the duration of maintenance treatment on an individual basis, offering the possibility of an early discontinuation (e.g., to reduce side effect burden), but also of a long‐lasting treatment in every disease stage (to reduce the relapse risk) (the guideline group decided that this issue will be further reviewed);

• to offer electroconvulsive therapy in cases of catatonia or ultra‐treatment resistance;

• to offer psychosocial interventions, exercise interventions and/or metformin (for weight gain);

• to offer CBT, psychoeducation, cognitive remediation and family interventions to every person with schizophrenia;

• to develop crisis plans and advance treatment arrangements to avoid compulsory admissions;

• to offer primarily CBT rather than antipsychotic drugs to persons at risk for developing psychosis (the group decided to reduce the strength of this recommendation).

In Module 4a, the most important change was that we weakened the recommendation for antipsychotic monotherapy and we defined conditions for the use of combination treatment (e.g., when clozapine treatment is not feasible; to treat different symptom domains; to reduce prolactin levels). Moreover, the side effect chapter was significantly extended and includes now myocarditis screening and new blood‐monitoring rules for clozapine.

Major changes were made to Module 4b, where four new recommendations were added:

• digital interventions such as avatar therapy (weak recommendation) as part of a holistic treatment approach;

• mindfulness‐based interventions (strong recommendation) for the improvement of positive symptoms;

• acceptance and commitment therapy (consensus recommendation) as add‐on treatment;

• eye movement desensitization and reprocessing (EMDR) or prolonged exposure (weak recommendation) for people with schizophrenia and PTSD.

Moreover, we increased the strength of recommendation for metacognitive training and systemic psychotherapy. We strengthened the recommendation for psychoeducation including families (strong recommendation) compared to bifocal psychoeducation (weak recommendation). Exercise interventions were also moved to a strong recommendation grade.

The chapter on schizophrenia in the elderly remained unchanged, as in this area still only limited evidence is available and new research reports could not be identified. The same applied for children and adolescence with schizophrenia. However, due to the clinical importance and the large body of evidence from adults, we decided to strengthen the clozapine recommendation for treatment resistance in people with schizophrenia <18 years (strong recommendation).

Compared to the UK National Institute for Health and Care Excellence (NICE) guidelines (2014, last reviewed in 2025 with no changes) and the American Psychiatric Association (APA) guidelines (2020), our new living guideline provides more clinically relevant details regarding the use of pharmacological, psychotherapeutic and other interventions, and is the first guideline in the field that has been fully developed within the evidence‐ecosystem MAGICapp.

The latest version of this guideline has been the basis for the European Psychiatric Association guidance on pharmacological treatment of schizophrenia ⁵ . The English version of this guideline has the potential to be used by many other organizations which do not have the resources to produce a complete de novo guideline.