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Schizophrenia

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Updated 2023 WHO, 2023 VA/DoD, 2022 AAFP, and 2020 BAP guidelines for the evaluation and management of schizophrenia.

Background

Overview

Definition
Schizophrenia is defined as a complex psychiatric condition characterized by symptoms of delusions, hallucinations, disorganized speech, and impaired cognitive functions.
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Pathophysiology
The exact cause of schizophrenia is unclear; however, in utero disorders (infections, obstetric complications, and fetal disturbances), and genetic and environmental factors (childhood trauma, social isolation, economic adversity, discrimination) have been implicated.
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Epidemiology
The annual prevalence of diagnosed schizophrenia in the US is 5.1 per 1,000 individuals.
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Disease course
Abnormalities (hypo/hyper) in neurotransmission of neurotransmitters (dopamine, serotonin, and glutamate), particularly dopamine results in either hyperdopaminergic function in the caudate nucleus or hypodopaminergic function in the frontal lobe, in addition to a complex interaction of nigrostriatal, mesolimbic, mesocortical, and tuberoinfundibular pathway leads to negative symptoms, positive symptoms, and cognitive deficits, in addition to detectable physical changes in the brain tissue.
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Prognosis and risk of recurrence
After 10-year follow up 80% of the schizophrenic patients require readmission after the first discharge. Non-adherence to anti-psychotic medication in the first year is associated with a 64% relapse rate while adherence during the first year is associated with a 27% relapse.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of schizophrenia are prepared by our editorial team based on guidelines from the United States Department of Defense (DoD/VA 2023,2019), the World Health Organization (WHO 2023), the American Academy of Family Physicians (AAFP 2022,2015), the American Psychiatric Association (APA 2020), and the British Association for Psychopharmacology (BAP 2020). ...
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Diagnostic investigations

Initial assessment
As per APA 2020 guidelines:
Include the following in the initial assessment of patients with a possible psychotic disorder:
reason the patient is presenting for evaluation
patient's goals and preferences for treatment
review of psychiatric symptoms and trauma history
psychiatric treatment history
assessment of tobacco use and other substance use
assessment of physical health
assessment of psychosocial and cultural factors
mental status examination, including cognitive assessment
assessment of the risk of suicide and aggressive behaviors, as outlined in APA's Practice Guidelines for the Psychiatric Evaluation of Adults (3rd edition)
B
Include a quantitative measure in the initial psychiatric evaluation of patients with a possible psychotic disorder to identify and determine the severity of symptoms and impairments of functioning that may be a focus of treatment.
B
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  • Brain imaging

  • Serum biomarkers

  • Pretreatment evaluation

Medical management

Initiation of antipsychotic therapy
As per DoD/VA 2023 guidelines:
Initiate an antipsychotic medication other than clozapine for the treatment of an acute episode in patients with schizophrenia or first-episode psychosis previously responded to antipsychotic medications. Decide on the choice of antipsychotic agent based on an individualized evaluation of patient characteristics and side effect profiles of different medications.
A
Consider initiating a trial of another antipsychotic medication in patients with schizophrenia not responding or tolerating an adequate trial of an initial antipsychotic medication. Decide on the choice of antipsychotic agent based on an individualized evaluation of patient-specific characteristics and side effect profiles of different medications.
C

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  • Clozapine

  • Long-acting injectable antipsychotics

  • Maintenance therapy

  • Adjunctive agents

  • Management of drug side effects

Nonpharmacologic interventions

General principles: as per DoD/VA 2023 guidelines, offer treatment/management with early intervention services in patients with first-episode psychosis.
A
insufficient evidence to recommend for or against any specific duration for participation in specialized early intervention services.
B
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  • CBT

  • Cognitive rehabilitation

  • Psychosocial interventions (psychoeducation)

  • Psychosocial interventions (supportive psychotherapy)

  • Psychosocial interventions (community treatment)

  • Psychosocial interventions (family interventions)

  • Psychosocial interventions (skills training)

  • Psychosocial interventions (supported employment)

  • Psychosocial interventions (supported housing)

  • Psychosocial interventions (technology-based interventions)

  • Lifestyle modifications

  • Acupuncture

Therapeutic procedures

Neuromodulation: as per DoD/VA 2023 guidelines, insufficient evidence to recommend for or against transcranial direct current stimulation, repetitive transcranial magnetic stimulation, or electroconvulsive therapy in patients with schizophrenia.
I

Specific circumstances

Adolescent patients
As per WHO 2023 guidelines:
Consider offering oral antipsychotics (such as aripiprazole, olanzapine, paliperidone, quetiapine, or risperidone) under specialist supervision in adolescent patients with psychotic disorders (including schizophrenia), carefully balancing effectiveness, side effects, and individual preference.
C
Consider offering clozapine in adolescent patients with treatment-resistant psychotic disorder (including schizophrenia) under specialist supervision, carefully balancing effectiveness, side effects, and individual preference.
C

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  • Pregnant patients

Follow-up and surveillance

Assessment of treatment response: as per BAP 2020 guidelines, monitor trials of antipsychotic efficacy using comprehensive symptom assessment scales, such as the Positive and Negative Syndrome Scale. Obtain assessments at baseline and at the end of a predetermined trial period, typically 2 weeks initially.
B
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