The revised German evidence‐ and consensus‐based schizophrenia guideline

The German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) has just completed and published its revised national guideline on schizophrenia1.

This guideline is evidence‐ and consensus‐based according to the methodological criteria for clinical guidelines fulfilling the highest quality standard (S3) of the Standing Guideline Commission of the German Association of Scientific Medical Societies (AWMF)². S3 standard is based on scientific evidence including systematic literature search and grading, evaluation and adaptation of available international high‐quality guidelines, and a scientifically sound formal consensus by means of nominal group processes, structured consensus conferences and possible additional use of the Delphi technique2.

For the revision process, the guideline was arranged into topic‐specific modules, which were updated by members of the Steering, Expert and Consensus Groups of the Association. Thirty‐eight stakeholders – including representatives from medical societies and other associations of the workforce from all fields involved in the diagnosis, treatment and care of schizophrenia, from patients’ and relatives’ advocacy groups, as well as more than 20 experts from different topic‐related disciplines – were involved in the process.

Standardized operational procedures to deal with all potential financial and non‐financial conflicts of interest were implemented. The guideline underwent several internal and external revision steps, including a public consultation phase, and was funded by the DGPPN without any public, ministerial or industry support. The guideline group produced a total of 162 recommendations and 8 statements. The document is freely available at the AWMF webpage (http://www.awmf.org), as a long (in German) and short (in German and English) version.

The guideline is structured in seven modules, covering all areas of diagnosis, treatment and management of schizophrenia. Module 1 describes the general principles of the management of schizophrenia, while module 2 focuses on differential diagnoses (including rare diseases such as autoimmune psychosis) and the detection of somatic comorbidities that may cause excess mortality. Module 3 describes the general aspects of treatment, focuses on developing course‐specific treatment plans, and emphasizes the need for shared decision making.

Module 4 includes the available treatment interventions in schizophrenia. Submodule 4a covers all aspects of pharmacological and biological treatments, with a particular emphasis on side effect prevention and management. Submodule 4b focuses on psychotherapeutic and psychosocial interventions and family care. Submodule 4c gives recommendations for treatment under special clinical circumstances, such as comorbid mental illnesses (e.g., depression, post‐traumatic stress disorder or obsessive‐compulsive disorder), agitation and aggression, substance use disorders (tobacco, alcohol and cannabis), catatonia; childhood, adolescence and the elderly; pregnancy and breast feeding; as well as in people being at risk for psychosis. Submodule 4d covers issues of medical, social and occupational rehabilitation.

Module 5 refers to care coordination and is giving recommendations for an integrated cooperation of all service providers. Most importantly, the guideline group also produced recommendations for the necessary staffing of psychiatric hospital care to guarantee an optimal guideline‐based treatment. Module 6 evaluates the cost‐effectiveness of treatments, and Module 7 covers quality management in schizophrenia treatment and care.

The German guideline gives recommendations with different strengths (A: we recommend; B: we suggest; 0: it may be considered; KKP: good‐clinical practice/expert recommendation), based on a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) terminology3.

Examples of particularly important recommendations are the following1: a) to offer regular monitoring of physical health to all persons with schizophrenia; b) to evaluate and classify symptoms suggesting typical medical comorbidities in every patient with schizophrenia; c) to offer magnetic resonance imaging to every person with a first‐episode schizophrenia; d) to offer acute and maintenance antipsychotic drug treatment using the lowest possible dosage to every person with schizophrenia; e) to select an antipsychotic drug mainly based on the side effect profile; f) to work out the duration of maintenance treatment on an individual basis, offering the possibility for an early discontinuation (e.g., to reduce side effect burden), but also for a long‐lasting treatment in every disease stage (to reduce the relapse likelihood); g) to offer clozapine monotherapy as soon as the criteria for treatment resistance are fulfilled, and antipsychotic drug combination treatment only if adequate response is not achieved with monotherapy with three different antipsychotics, including clozapine; h) to offer electroconvulsive treatment in cases of catatonia; i) to offer psychosocial interventions, exercise interventions and/or metformin (or topiramate) for weight gain; j) to offer cognitive behavioural therapy (CBT), psychoeducation and family interventions to every person with schizophrenia; k) to develop crisis plans and advance treatment arrangements to avoid compulsory admissions; l) to offer primarily CBT rather than antipsychotic drugs to persons at risk for developing psychosis, and m) to wait for two weeks before switching antipsychotic drugs in case of depressive symptoms, but also to offer an add‐on antidepressant in case of a significant depressive syndrome. These examples highlight the scope of the guideline content, but should not be used in clinical practice without consulting the original text.

Compared to the guidelines of the UK National Institute for Health and Care Excellence (NICE)4, the German guideline is putting more emphasis on specific challenging clinical situations and has involved a broad spectrum of stakeholders, which adds to its representativeness and acceptance.

We are planning to submit the currently available major schizophrenia guidelines, including our own, to a systematic quality check by using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument, as has been done with former guideline versions5.

For the future, we believe that an international high‐quality “core guideline” , based on best available evidence and “neutral” international consensus, should be developed by the WPA and other international associations and stakeholders. This guideline should then be adapted to the special needs of national health care systems by the national psychiatric and other associations and stakeholders. This would have the potential to improve overall care for patients with schizophrenia, to harmonize treatment across countries and to reduce guideline developmental costs per country.