Revised guidelines on the assessment and treatment of schizophrenia were released by the American Psychiatric Association in the fall of 2020, marking the first time the recommendations had been updated since 2004.1,2 The decision for the new changes was largely sparked by a systematic review led by McDonagh et al, that had been commissioned by the Agency for Healthcare Research and Quality (AHRQ).3  McDonagh’s team reported on new antipsychotics released into the market, including the role of VMAT2 inhibitors in managing tardive dyskinesia (TD) symptoms, and provided a more in-depth summary of antipsychotics with regard to optimizing and individualizing medication choices.

In addition to discussing new treatment options for TD, the updated guideline includes evidence-based reviews of psychosocial interventions and a summary of antipsychotics characteristics to aid clinicians in treatment decisions.

The 2004 guidelines were categorized into three sections: treatment recommendations for patients with schizophrenia, background information and review of the available evidence, and future research directions. The new recommendations are categorized into three categories as well, however, they are defined as:

  1. initial assessment and treatment planning
  2. pharmacotherapy
  3. psychosocial interventions

The following summarizes the new guidelines, which emphasize shared-decision making and patient preference.

Schizophrenia: Initial Assessment and Treatment Planning

When initially assessing individuals for schizophrenia, the American Psychiatric Association now recommends conducting a detailed evaluation of the patient’s laboratory tests and physical health to improve diagnostic accuracy as well as decision-making around treatment safety and appropriateness.

Specific tests, such as imaging, genetic testing, or electroencephalography (EEG) are recommended to help identify concomitant conditions present that may increase the individual’s risk of developing schizophrenia.

Additionally, the association advises clinicians treating those with schizophrenia to be aware of and to look for the development of secondary conditions that have been associated with the use of common schizophrenia medications. These developments may include diabetes, hyperlipidemia, metabolic syndrome, hyperprolactinemia, QTc prolongation, and antipsychotic-induced movement disorders. Specifically:

  1. APA recommends (1C) that the initial assessment of a patient with a possible psychotic disorder include the reason the individual is presenting for evaluation, the patient’s goals and preferences for treatment, a review of psychiatric symptoms and trauma history, an assessment of tobacco use and other substance use, a psychiatric treatment history, an assessment of physical health, an assessment of psychosocial and cultural factors, a mental status examination including cognitive assessment, and an assessment of risk of suicide and aggressive behaviors.
  2. APA recommends (1C) that the initial psychiatric evaluation of a patient with a possible psychotic disorder include a quantitative measure to identify and determine the severity of symptoms and impairments of functioning that may be a focus of treatment.
  3. APA recommends (1C) that patients with schizophrenia have a documented, comprehensive, and person-centered treatment plan that includes evidence-based nonpharmacological and pharmacological treatments.1

Updated Pharmacotherapy Options for Schizophrenia

The new practice guidelines present evidence-guided pharmacotherapy for treatment.

The American Psychiatric Association now recommends the use of antipsychotics in the treatment of schizophrenia with no specific preference between first- and second-generation antipsychotics. In the 2004 guidelines, second-generation antipsychotics were recommended as first-line in the acute phase of schizophrenia.

In the updated guidelines, the association emphasizes focusing on the side-effect profile, formulation availability, drug-drug interactions, and metabolism of the antipsychotic agents when selecting the agent of choice. Furthermore, the association recommends the continuation of antipsychotic medications if improvements were seen.

Other noteworthy medication recommendations from the new guidelines include:

  • clozapine for treatment-resistant schizophrenia, the presence of suicide risk, and aggressive behavior
  • consider the role of anticholinergic medications for acute dystonia
  • when treating Parkinsonism associated with antipsychotic therapy, consider lowering the dose, switching to another antipsychotic medication, or treating with an anticholinergic medication
  • when treating akathisia associated with antipsychotic therapy, consider benzodiazepine, beta-adrenergic blocking agent, or switching to another antipsychotic drug
  • VMAT2 medications for the treatment of tardive dyskinesia (see also, our consumer overview and patient stories on TD)
  • long-acting injectable antipsychotics for those who prefer them

Updated Psychosocial Interventions for Schizophrenia

Psychosocial interventions remain a cornerstone of schizophrenia treatment – but the 2004 guidelines left the benefits of such approaches rather ambiguous. With new data, the 2020 guidelines detail the specific benefits of psychosocial interventions, including increased functional outcomes and mortality.

Coordinated specialty care programs are recommended for patients experiencing their first episode of psychosis. According to the McDonagh paper and a study conducted by Anderson4 and colleagues, data now shows that early psychosis intervention is associated with reduced mortality, lower rates of relapse, and better functional and social outcomes compared to those who do not receive interventions.

Other psychosocial interventions noted in the 2020 update as being associated with better outcomes include:

  • CBT for psychosis
  • psychoeducation
  • supported employment services
  • assertive community treatment
  • family interventions
  • self-management skills
  • recovery-focused interventions
  • cognitive remediation
  • social skills training
  • supportive psychotherapy

See also, the full detailed guidelines.

Professional Takeaways

Overall, there are many similarities between the old and new American Psychiatry Association schizophrenia treatment practice guidelines, however, the updated version takes into consideration new research demonstrating the benefits of psychosocial interventions, new treatment options for TD utilizing VMAT2 medications, and clarifies that either first-generation or second-generation antipsychotics may be used as first-line treatment.

The updated guidelines also provide a more evidence-based discussion on various recommendations based on the prior AHRQ review3 and clinical studies.

References
Last Updated: Mar 4, 2021