Guideline sources The following summarized guidelines for the evaluation and management of schizophrenia are prepared by our editorial team based on guidelines from the American Psychiatric Association (APA 2020). 1 3 3 4 4 4 5 Definition Schizophrenia is defined as a complex psychiatric condition characterized by symptoms of delusions, hallucinations, disorganized speech, and impaired cognitive functions. 3 Epidemiology 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. 4 Pathophysiology The annual prevalence of diagnosed schizophrenia in the United States is 5.1 per 1,000 individuals. 4 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 https://web.pathway.md/diseases/recWS188455LqmB72 1/4 6/24/23, 3:05 PM Schizophrenia Pathway 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. 4 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. 3 5 Guidelines 1. Diagnostic investigations Initial assessment: Include the following in the initial assessment of patients with 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 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 possible psychotic disorder to identify and determine the severity of symptoms and impairments of functioning that may be a focus of treatment. B 2. Medical management Antipsychotics (indications): initiate an antipsychotic medication in patients with schizophrenia and monitor for effectiveness and side effects. A Show 2 more Antipsychotics (clozapine): Offer clozapine in patients with schizophrenia: with treatment-resistant disease if the risk for suicide attempts or suicide remains substantial despite other treatments. B https://web.pathway.md/diseases/recWS188455LqmB72 2/4 6/24/23, 3:05 PM Schizophrenia Pathway Consider offering clozapine in patients with schizophrenia if the risk for aggressive behavior remains substantial despite other treatments. C Antipsychotics (long-acting injectable agents): consider administering a long-acting injectable antipsychotic medication in patients with schizophrenia if they prefer such treatment or if they have a history of poor or uncertain adherence. C Antipsychotics (management of side effects): administer an anticholinergic medication in patients with schizophrenia having acute dystonia associated with antipsychotic therapy. B Show 3 more 3. Nonpharmacologic interventions General principles: Ensure a documented, comprehensive, and person-centered treatment plan that includes evidence-based nonpharmacological and pharmacological treatments for patients with schizophrenia. B Manage patients with schizophrenia experiencing a first episode of psychosis in a coordinated specialty care program. B Cognitive therapies (cognitive behavioral therapy): offer CBT for psychosis in patients with schizophrenia. B Cognitive therapies (cognitive remediation): consider offering cognitive remediation in patients with schizophrenia. C Psychosocial interventions (psychoeducation): offer psychoeducation in patients with schizophrenia. B Psychosocial interventions (supportive psychotherapy): consider offering supportive psychotherapy in patients with schizophrenia. C Psychosocial interventions (community treatment): offer assertive community treatment in patients with schizophrenia if there is a history of poor engagement with services leading to frequent relapse or social disruption (such as homelessness, legal difficulties, including imprisonment). B Psychosocial interventions (family interventions): consider offering family interventions in patients with schizophrenia having ongoing contact with the family. C Psychosocial interventions (skills training): Consider offering interventions aimed at developing self-management skills and enhancing person-oriented recovery in patients with schizophrenia. C Consider offering social skills training in patients with schizophrenia having a therapeutic goal of enhanced social functioning. C Psychosocial interventions (supported employment): offer supported employment services in patients with schizophrenia. B https://web.pathway.md/diseases/recWS188455LqmB72 3/4 6/24/23, 3:05 PM Schizophrenia Pathway References 1. George A Keepers, Laura J Fochtmann, Joan M Anzia et al. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia. Am J Psychiatry. 2020 Sep 1;177 9 868 872. Open 2. James Sall, Lisa Brenner, Amy M Millikan Bell et al. Assessment and Management of Patients at Risk for Suicide: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines. Ann Intern Med. 2019 Sep 3;171 5 343 353. Open 3. E L Berson, M A Sandberg, T P Dryja. Autosomal dominant retinitis pigmentosa with rhodopsin, valine- 345-methionine. 1991;89 117 28; discussion 128 30.1991;89 117 28; discussion 128 30. Open 4. Krishna R Patel, Jessica Cherian, Kunj Gohil et al. Schizophrenia: overview and treatment options. 2014 Sep;39 9 638 45.2014 Sep;39 9 638 45. Open 5. Gioia Mura, Donatella Rita Petretto, Krishna M Bhat et al. Schizophrenia: from epidemiology to rehabilitation. 2012;8 52 66.2012;8 52 66. Open 6. Hadjulis M, Margariti M, Lazaridou M et al. Clinical guidelines for the management of schizophrenia: Pharmacological and psychological interventions III . Psychiatriki. 2018 Oct-Dec;29 4 303 315. Open 7. Grover S, Avasthi A. Clinical Practice Guidelines for the Management of Schizophrenia in Children and Adolescents. Indian J Psychiatry. 2019 Jan;61 Suppl 2 277 293. Open 8. Thomas Re Barnes, Richard Drake, Carol Paton et al. Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2020 Jan;34 1 3 78. Open 9. Stephen K Brannan, Sharon Sawchak, Andrew C Miller et al. Muscarinic Cholinergic Receptor Agonist and Peripheral Antagonist for Schizophrenia. N Engl J Med. 2021 Feb 25;384 8 717 726. Open 10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision DSM 5 TR ). APA. 2022. Open https://web.pathway.md/diseases/recWS188455LqmB72 4/4