TABLE 4.
Practice Assessment Tool for the Care of Patients With a Diagnosis of Schizophrenia, part 3: treatments indicated for patient-specific needs or circumstancesa
| Patient | |||||||
|---|---|---|---|---|---|---|---|
| Aspect of care and quality-related action | 1 | 2 | 3 | 4 | 5 | Total no. of patients with check marks OR circled NAs in each rowb | Supporting evidence, resources, and clinical issues for consideration |
| 19. Clozapine, for individuals with treatment-resistant symptoms | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Clozapine should be offered to individuals with schizophrenia who have treatment-resistant schizophrenia because its use is associated with a higher rate of treatment response, reduction in psychotic symptoms, and lower rates of all-cause mortality, hospitalization, and treatment discontinuation resulting from lack of efficacy (138). A common definition of treatment-resistant schizophrenia is that a patient’s symptoms have shown no response or partial and suboptimal response to two antipsychotic medication trials of at least six weeks each at an adequate dose of medication, and some definitions specify using medications from different classes (e.g., second-generation antipsychotic vs. first-generation antipsychotic). However, if there is no significant improvement after several weeks of treatment (e.g., <20% improvement in symptoms), the likelihood of substantial improvement (e.g., >50% improvement in symptoms) is small (129, 130), and a longer trial of the medication may not be warranted. It should also be noted that a medication trial cannot be viewed as adequate if it is truncated in terms of duration or dosage because of poor tolerability or if limited by poor adherence. |
| 20. Clozapine, for individuals with a substantial risk for suicide attempts or suicide despite other treatments | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Regardless of whether criteria for treatment-resistant schizophrenia are met, clozapine should be offered to individuals with schizophrenia who have substantial risk for suicide attempts or suicide despite other treatments because clozapine use is associated with lower rates of self-harm, suicide attempts, and hospitalizations to prevent suicide (138). |
| 21. Clozapine, for individuals with a substantial risk for aggressive behavior despite other treatments | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Although evidence is less robust than for use of clozapine for treatment-resistant schizophrenia or persistent risk of suicide, treatment with clozapine can also be effective in reducing aggressive behavior. As in other circumstances in which patients do not appear to be responding fully to treatment, attention to adherence is crucial. |
| 22. An LAIc antipsychotic, for individuals with a history of poor or uncertain adherence, or a preference for LAI treatment | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | An LAI formulation of an antipsychotic medication is suggested for individuals with schizophrenia who prefer LAI medication or have a history of poor or uncertain adherence. In addition to patients who have had difficulty in adhering to oral medications, this may include individuals who have limited awareness of having an illness, who have not responded to treatment with an oral medication, who have a history of frequent relapses on oral medication, or who are transitioning between treatment settings where adherence may be difficult. Although randomized controlled trials do not show evidence of benefit from LAIs relative to oral antipsychotic medications, observational data from nationwide registry databases, cohort studies, and “mirror image” studies suggest that use of LAI antipsychotic agents as compared with oral antipsychotic medications is associated with a decreased risk of mortality, reduced risk of hospitalization, and decreased rates of study discontinuation, including discontinuation due to inefficacy (153–158). Thus, the benefits associated with use of an LAI formulation of an antipsychotic medication are at least as good as the benefits of an oral formulation and may be better, with no significant differences in side effects between oral and LAI formulations. |
| 23. Anticholinergic medications, for individuals with acute dystonia associated with antipsychotic therapy | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Clinical experience suggests that acute dystonia can be ameliorated by administration of diphenhydramine, a histamine receptor antagonist with anticholinergic properties. Typically, it is administered intramuscularly to treat acute dystonia, but it can also be administered intravenously in emergent situations, as with acute dystonia associated with laryngospasm. Alternatively, benztropine can be administered intramuscularly. Once the acute dystonia has resolved, it may be necessary to continue an oral anticholinergic medication such as benztropine or trihexyphenidyl to prevent recurrence, at least until other changes in medications can take place, such as reducing the dose of medication or changing to an antipsychotic medication that is less likely to be associated with acute dystonia. Whenever an anticholinergic medication is prescribed, it is important to be mindful of the potential for medication side effects and interactions with other medications that a patient is taking. |
| 24. Medication changes, for individuals with parkinsonism associated with antipsychotic therapy | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | For patients who have parkinsonism associated with antipsychotic therapy, the following options can be considered: lowering the dosage of the antipsychotic medication, switching to another antipsychotic medication, or treating with an anticholinergic medication. However, before reducing the dose of medication or changing to another antipsychotic medication, the benefits of reduced parkinsonism should be weighed against the potential for an increase in psychotic symptoms. The use of an anticholinergic medication is another option, either on a short-term basis, until a change in dose or a change in medication can occur, or on a longer term basis, if a change in dose or change in medication is not feasible. It should be noted that different symptoms of parkinsonism (e.g., rigidity, tremors, akinesia) may have a differential response to anticholinergic medications, and different treatment approaches may be needed to address each of these symptoms. If an anticholinergic medication is prescribed, it is important to be mindful of the potential for medication side effects and interactions with other medications that a patient is taking. |
| 25. Medication changes, for individuals with akathisia associated with antipsychotic therapy | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | For patients who have akathisia associated with antipsychotic therapy, the following options can be considered: lowering the dosage of the antipsychotic medication, switching to another antipsychotic medication, adding a benzodiazepine medication, or adding a beta-adrenergic blocking agent. In contrast, akathisia tends not to respond to anticholinergic agents (159). Before reducing the dose of medication or changing to another antipsychotic medication, the benefits of reduced akathisia should be weighed against the potential for an increase in psychotic symptoms. In addition, it is important to assess for dysphoria, which may be associated with akathisia, and to distinguish between akathisia and restlessness or agitation associated with anxiety or psychosis. |
| 26. VMAT2d medications, for individuals with moderate to severe or disabling tardive dyskinesia | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Evaluation for the presence of tardive syndromes is important to identify them, minimize worsening, and institute clinically indicated treatment. Regular assessment of patients for tardive syndromes through clinical examination or use of a structured evaluative tool (e.g., AIMS, DISCUSe) can aid in identifying tardive syndromes, clarifying their likely etiology, monitoring their longitudinal course, and determining the effects of medication changes or treatments for tardive dyskinesia (see Table 1). If no contributing etiology is identified, as discussed in the full text of the guideline, and moderate to severe or disabling tardive dyskinesia persists, treatment is recommended with a reversible VMAT2 inhibitor. Treatment with a VMAT2 inhibitor can also be considered for patients with mild tardive dyskinesia on the basis of factors such as patient preference, associated impairment, or effect on psychosocial functioning. In general, deutetrabenazine or valbenazine are preferred over tetrabenazine because of the greater evidence base supporting their use. However, tetrabenazine and deutetrabenazine are contraindicated for individuals with hepatic impairment, whereas valbenazine is not recommended for use with individuals with severe renal impairment. In addition, anticholinergic medications are not helpful and may worsen tardive dyskinesia (160). |
| 27. CSCf program (e.g., NAVIGATE/RAISE), for individuals experiencing a first episode of psychosis | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | CSC programs, which are sometimes referred to as team-based, multicomponent interventions, provide a comprehensive package of treatment that integrates collaborative, shared decision making with approaches such as family involvement and education, individual resiliency training, supported employment and education, and individualized medication treatment (161, 162). Similar CSC programs have also been used for treatment of early psychosis (163–165). When CSC programs are unavailable, advocacy may be needed to encourage program development; materials are available to help guide the establishment of new programs with evidence-based approaches (162, 166, 167). |
| 28. ACT,g for individuals with a history of poor engagement with services leading to frequent relapse or social disruption (e.g., homelessness, legal issues) | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | ACT is a multidisciplinary, team-based approach in which patients receive personalized and flexible care outside of a formal clinical setting with the aim of addressing patients’ needs and preferences without time limits or other constraints on services. Because availability of ACT programs is often limited, advocacy may be needed to encourage program development and high fidelity to ACT program standards (168–171). |
| 29. Supportive psychotherapy, for individuals who are not able to receive or prefer not to receive an evidence-based psychotherapy for psychosis | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Supportive psychotherapy is commonly a part of the treatment plan for individuals with schizophrenia who are not receiving other modes of psychotherapy (e.g., CBTph). Supportive psychotherapy commonly aims to help patients cope with symptoms, improve adaptive skills, and enhance self-esteem. Examples of techniques used to foster these goals include reassurance, praise, encouragement, explanation, clarification, reframing, guidance, suggestion, and use of a conversational, nonconfrontational style of communication. Many of the common elements that have been identified in effective psychotherapies, including a positive therapeutic alliance, are also integral to supportive psychotherapy (172, 173). Because the evidence related to its benefits is limited, supportive psychotherapy should not take precedence over other evidence-based psychosocial treatments (e.g., coordinated specialty care, CBTp, psychoeducation). |
| 29. Cognitive remediation, for individuals with cognitive difficulties | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Cognitive remediation approaches are intended to address cognitive difficulties that can accompany schizophrenia with the aim of enhancing function and quality of life. A number of different cognitive remediation approaches have been used, typically in group- or computer-based formats, in an effort to enhance cognitive processes such as attention, memory, executive function, social cognition, or meta‐cognition (174–178). Some programs add aspects of social and communication skills to neurocognitive elements of remediation (179). The primary barriers to use of cognitive remediation are related to program availability. Advocacy may be needed to encourage program development (174, 178). Web-based programs have been used in clinical trials and may provide options for patients without access to in-person programs (180, 181). |
| 30. Social skills training, for individuals who have a therapeutic goal of enhanced social functioning | □ NA | □ NA | □ NA | □ NA | □ NA | __/5 | Social skills training has an overarching goal of improving interpersonal and social skills, but it can also improve core illness symptoms and negative symptoms more than usual care (138). Social skills training can include cognitive-behavioral, social-cognitive, interpersonal, and functional adaptive skills training (55, 182, 183). It is delivered in a group format and includes homework assignments to facilitate skill acquisition. In some social skills training programs, group sessions are augmented with video or technologically based interventions, community trips to practice social skills (184, 185), and involvement of support people who are accessible, pleasant, and knowledgeable about the local environment’s resources and limitations (185, 186). Advocacy may be needed to encourage program development; information about social skills training is available for organizations that want to develop such programs (187–189). |
a
A number of other evidence-based interventions are important to consider when developing treatment plans because they have been shown to be beneficial to patients with specific needs or in specific clinical circumstances. If the index intervention was provided or offered to the select patient, please check the appropriate box; if no or unknown, leave the box unchecked. If the patient does not qualify to receive the indicated intervention, please circle NA.
b
Scoring: In the total column, tally the total number of check marks and circled NAs in each row. For any row for which the total is less than five, examine whether clinical or other circumstances explain why practice was not consistent with recommended care or whether the indicated treatment is not currently available and therefore not applicate for the patient. Consider whether changes in your practice could strengthen the provision of evidence-based care or whether advocacy efforts are needed to make evidence-based services more available. NA, not applicable.
c
LAI, long-acting injectable.
d
VMAT2, vesicular monoamine transporter 2.
e
AIMS, Abnormal Involuntary Movement Scale; DISCUS, Dyskinesia Identification System: Condensed User Scale.
f
CSC, coordinated specialty care.
g
ACT, assertive community treatment.
h
CBTp, cognitive-behavioral therapy for psychosis.