Mental Health Practice Guidelines
The below guidelines are meant for mental health professionals to use in their clinical practices. Please be aware that there are various authoring organizations. The NGC has summarized these guidelines. Links are provided to the original source within the guideline documents.
Guideline Title
Schizophrenia.
Bibliographic Source(s)
Singapore Ministry of Health. Schizophrenia. Singapore: Singapore Ministry of Health; 2003 Feb. 40 p. [29 references]
Guideline Status
This is the current release of the guideline.
FDA Warning/Regulatory Alert
Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released. On January 13, 2006, Novartis and the U.S. Food and Drug Administration (FDA) notified healthcare professionals of revisions to the BOXED WARNING, WARNINGS, CONTRAINDICATIONS, PRECAUTIONS (Information for Patients and Pharmacokinetic-Related Interactions subsections), and ADVERSE REACTIONS (Postmarketing Clinical Experience subsection) sections of the prescribing information for Clozaril (clozapine) tablets. Recommendations from the FDA's Psychopharmacological Drugs Advisory Committee regarding the white blood cell monitoring schedule, required for all clozapine users, has resulted in modification in the monitoring schedule. Additional labeling changes address safety issues related to dementia-related psychosis, parlytic ileus, hypercholesterolemia and pharmacokinetic interaction with citalopram. See the FDA Web site for more information.
Disease/Condition(s)
Schizophrenia
Guideline Category
EvaluationManagementTreatment
Clinical Specialty
Family PracticePsychiatryPsychology
Intended Users
Allied Health PersonnelPhysiciansPsychologists/Non-physician Behavioral Health CliniciansSocial Workers
Guideline Objective(s)
To provide guidance to doctors on the many treatment options available for schizophrenia, based on the best available evidence from the medical literature To provide patients with schizophrenia with the best possible care and outcome To assist primary health care physicians in clinical decision-making
Target Population
Adults with schizophrenia in Singapore
Interventions and Practices Considered
Diagnosis and Assessment Assessment of patient for symptoms of schizophrenia, co-morbid psychiatric illness, co-morbid medical condition, or substance abuse Evaluation of patient's social supports, functioning, and relative risk of self-harm or harm to others Treatment Pharmacotherapy First-line antipsychotic medications (trifluoperazine, chlorpromazine, thioridazine, haloperidol, sulpiride) Second-line antipsychotic medications (clozapine, risperidone, olanzapine, quetiapine, amisulpride) Depot antipsychotic medications Maintenance and discontinuation of antipsychotics Adjunctive medications, including anticholinergic agents, benzodiazepines, mood stabilizers (e.g., lithium, carbamazepine, valproate), and antidepressants Monitoring of response to medications and adjustments as necessary Electroconvulsive therapy (ECT) Psychosocial interventions Individual and group psychological therapy Psychoeducation/family intervention Social skills training Vocational training Referral to psychiatrist
Major Outcomes Considered
Effectiveness and safety of medications Side effects, adverse effects, and costs of treatment Rates of relapse, coping skills, social and vocational functioning, and ability to function independently
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Not stated
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Levels of Evidence Level Ia: Evidence obtained from meta-analysis of randomised controlled trials. Level Ib: Evidence obtained from at least one randomised controlled trial. Level IIa: Evidence obtained from at least one well-designed controlled study without randomisation. Level IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study. Level III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies. Level IV: Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.
Methods Used to Analyze the Evidence
Review of Published Meta-AnalysesSystematic Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Grades of Recommendations Grade A (evidence levels Ia, Ib): Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation. Grade B (evidence levels IIa, IIb, III): Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation. Grade C (evidence level IV): Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates absence of directly applicable clinical studies of good quality. Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group.
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Not stated
Description of Method of Guideline Validation
Not applicable
Major Recommendations
The recommendations that follow are those from the guideline's executive summary; detailed recommendations can be found in the original guideline document. Each recommendation is rated based on the level of the evidence and the grades of recommendation. Definitions of the grades of the recommendations (A, B, C, Good Practice Points) and level of the evidence (Level I-Level IV) are presented at the end of the Major Recommendations field. A - Antipsychotic medications are the first-line treatment for psychotic symptoms. (Grade A, Level Ia) A - Clozapine is not used as a first-line antipsychotic because of the risk of agranulocytosis. Its use is to be considered only after other antipsychotic medications prove inadequate; it can only be prescribed by a registered psychiatrist, and regular blood monitoring is mandatory. (Grade A, Level Ia) A - Most patients respond to a daily antipsychotic dose of 300 to 1,000 chlorpromazine (CPZ) equivalents administered for a minimum of 6 weeks (Dixon, Lehman, & Levine, 1995). Patients with a first episode respond to lower doses than patients with recurrent episodes (McGorry, 1999; Remington, Kapur, & Zipursky, 1998; McEvoy, Hogarty, & Steingard, 1991). (Grade A, Level Ia) GPP - Local Asian patients may respond to a lower daily antipsychotic dose. (GPP) A - Maintenance dose is generally lower than that used in acute treatment, and the patient should continue with the lowest effective dose of antipsychotic medication. Dosages in excess of 600 CPZ equivalents/day should be avoided unless there are good clinical reasons (e.g., symptom control) for a higher dose (Dixon, Lehman & Levine, 1995). (Grade A, Level Ia) B - Patients who have not responded to recommended antipsychotic medications should be considered for electroconvulsive therapy (ECT). (Grade B, Level III) C - The prophylactic use of anticholinergic agents should be determined on a case-by-case basis, taking into account risk factors for both extrapyramidal side effects (EPSE) and anticholinergic side effects as well as the propensity of the antipsychotic medication to cause extrapyramidal side effects. (Grade C, Level IV) B - Patients who experience persistent and clinically significant symptoms of anxiety and those with disruptive, dangerous, or assaultive behaviour should receive a trial of adjunctive benzodiazepines (Johns & Thompson, 1995). (Grade B, Level III) B - Antidepressants should be considered for persistent depressive symptoms and should be prescribed with an antipsychotic to prevent worsening of psychosis (Black & Andresean, 1999). (Grade B, Level IIb) B - Supportive individual and group psychotherapy in combination with medications can reduce relapses and enhance occupational and vocational functioning (Scott & Dixon, 1995). (Grade B, Level IIb) A - Cognitive Behavioural Therapy is beneficial in reducing the symptoms (especially the positive symptoms) of schizophrenia (Garety, Fowler, & Kuipers, 2000). (Grade A, Level Ia) A - Psychoeducation and family intervention can help reduce relapse rates. (Grade A, Level Ib) A - Social skills training improves social adjustment and coping skills, thereby reducing relapse rates (Benton & Schroeder, 1990; Corrigan, 1991). (Grade A, Level Ib) A - Vocational training is likely to benefit those who a) see competitive employment as a personal goal, b) have a history of prior competitive employment, c) have a minimal history of psychiatric hospitalization, and d) have been assessed to have good work skills (Lehman, 1995). (Grade A, Level Ib) Definitions: Grades of Recommendations Grade A (evidence levels Ia, Ib): Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation. Grade B (evidence levels IIa, IIb, III): Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation. Grade C (evidence level IV): Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates absence of directly applicable clinical studies of good quality. Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group. Levels of Evidence Level Ia: Evidence obtained from meta-analysis of randomised controlled trials. Level Ib: Evidence obtained from at least one randomised controlled trial. Level IIa: Evidence obtained from at least one well-designed controlled study without randomisation. Level IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study. Level III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies. Level IV: Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.
Clinical Algorithm(s)
An algorithm is provided for pharmacological treatment of schizophrenia in the acute phase.
References Supporting the Recommendations
Benton MK, Schroeder HE. Social skills training with schizophrenics: a meta-analytic evaluation. J Consult Clin Psychol 1990 Dec;58(6):741-7. PubMedBlack DW, Andresean NC. Schizophrenia. Schizophreniform disorder, and delusional (paranoid) disorders. In: Hales RE, Yudofsky SC, Talbot JA, editor(s). Textbook of psychiatry. Washington (DC): American Psychiatric Press; 1999. p. 425-77.Corrigan PW. Social skills training in adult psychiatric populations: a meta-analysis. J Behav Ther Exp Psychiatry 1991 Sep;22(3):203-10. PubMedDixon LB, Lehman AF, Levine J. Conventional antipsychotic medications for schizophrenia. Schizophr Bull 1995;21(4):567-77. [40 references] PubMedGarety PA, Fowler D, Kuipers E. Cognitive-behavioral therapy for medication-resistant symptoms. Schizophr Bull 2000;26(1):73-86. [57 references] PubMedJohns CA, Thompson JW. Adjunctive treatments in schizophrenia: pharmacotherapies and electroconvulsive therapy. Schizophr Bull 1995;21(4):607-19. [85 references] PubMedLehman AF. Vocational rehabilitation in schizophrenia. Schizophr Bull 1995;21(4):645-56. [45 references] PubMedMcEvoy JP, Hogarty GE, Steingard S. Optimal dose of neuroleptic in acute schizophrenia. A controlled study of the neuroleptic threshold and higher haloperidol dose. Arch Gen Psychiatry 1991 Aug;48(8):739-45. PubMedMcGorry PD. Recommended haloperidol and risperidone doses in first-episode psychosis. J Clin Psychiatry 1999 Nov;60(11):794-5. PubMedRemington G, Kapur S, Zipursky RB. Pharmacotherapy of first-episode schizophrenia. Br J Psychiatry Suppl 1998;172(33):66-70. [29 references] PubMedScott JE, Dixon LB. Psychological interventions for schizophrenia. Schizophr Bull 1995;21(4):621-30. [42 references] PubMed
Type of Evidence supporting the Recommendations
The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").
Potential Benefits
Overall Benefits This guideline will provide guidance to doctors on the many treatment options available for schizophrenia and provide patients with the best possible care and outcome. Psychosocial interventions can improve the course of schizophrenia when integrated with psychopharmacologic treatment by providing additional benefits for patients in such areas as relapse prevention, improved coping skills, better social and vocational functioning, and ability to function more independently. Specific Benefits Typical antipsychotic medications have been convincingly shown in well over 100 randomised double-blind studies to be more effective than placebo in the treatment of positive symptoms. There is evidence that atypical antipsychotics are more or equally effective in controlling all four categories of symptoms in schizophrenia and are better tolerated than typical antipsychotics. Controlled trials have shown that clozapine produces significant improvement in at least 30% of patients who show an inadequate response to two typical antipsychotics of different clinical classes. Electroconvulsive therapy (ECT) is effective for schizophrenic patients with affective or catatonic symptoms. Randomised trials have demonstrated that a combination of family intervention with antipsychotics reduce 1-year relapse rates from a 40 to 53% range to a 2 to 23% range. Studies have shown that, when combined with medications, individual and group psychological therapy reduces relapses and enhances occupational and vocational functioning. Cognitive Behavioral Therapy (CBT) has been demonstrated to be beneficial in reducing the symptoms (especially positive symptoms) of schizophrenia. Studies show that social skills training improves social adjustment and coping skills, thereby reducing relapse rates. Controlled studies have shown that vocational interventions can be effective in helping patients find jobs and remain in competitive employment. Characteristics of patients who are more likely to benefit are those who a) see competitive employment as a personal goal, b) have a history of prior competitive employment, c) have a minimal history of psychiatric hospitalization, and d) have been assessed to have good work skills.
Potential Harms
Side Effects of Typical Antipsychotics Extrapyramidal side effects (e.g., acute dystonia, akathisia, parkinsonism) Tardive dyskinesia (involuntary movement disorder) following prolonged use Anticholinergic effects (e.g., dry mouth, blurred vision, urinary hesitancy or retention, constipation) Anti-adrenergic effects (e.g., postural hypotension, inhibition of ejaculation) Sedation Lowered seizure threshold Cardiovascular effects include electrocardiogram (ECG) changes (e.g., widening of QRS complex, prolonged QT interval), tachycardia, cardiac arrhythmias Hyperprolactinaemia (amenorrhoea, galactorrhoea, and breast enlargement in women and impotence and/or gynaecomastia in men) Skin and eye effects include allergic and phototoxic skin reactions; long-term use may cause pigmentary changes of skin, and corneal and lens deposits Hepatic effects (e.g., minor abnormalities in liver function tests, cholestatic jaundice) Neuroleptic malignant syndrome (a rare idiosyncratic and potentially fatal reaction characterized by hyperthermia, muscular rigidity, autonomic instability, alteration in consciousness level, and elevated serum creatinine phosphokinase) Others (e.g., weight gain, nausea) Common Side Effects of Atypical Antipsychotics Clozapine Sedation Hypersalivation Anticholinergic effects Weight gain Postural hypotension Potentially serious agranulocytosis (about 0.34% per annum) Potentially serious lowered seizure threshold in doses beyond 600 mg daily Olanzapine Weight gain Sedation Dizziness Anticholinergic effects (dry mouth, constipation, retention of urine, blurring of vision) Quetiapine Somnolence Dizziness Postural hypotension Anticholinergic effects (dry mouth, constipation, retention of urine, blurring of vision) Risperidone Insomnia Anxiety Agitation Hyperprolactinaemia (amenorrhoea, galactorrhoea, sexual dysfunction) Amisulpride Insomnia Anxiety Agitation Hyperprolactinaemia (amenorrhoea, galactorrhoea, sexual dysfunction) Cautions for Use of Benzodiazepines Patients with respiratory difficulties should be treated with caution. All patients should be considered for gradual withdrawal at the earliest opportunity to avoid an unnecessary risk of dependence, and all patients should be observed for the paradoxical effect of disinhibition.
Qualifying Statements
These guidelines are not intended to serve as standards of medical care. Standards of medical care are determined on the basis of all clinical data available for an individual case and are subject to change as scientific knowledge advances and patterns of care evolve. The contents of the guideline document are guidelines to clinical practice, based on the best available evidence at the time of development. Adherence to these guidelines may not ensure a successful outcome in every case, nor should they be construed as including all proper methods of care or excluding other acceptable methods of care. Each physician is ultimately responsible for the management of his/her unique patient in the light of the clinical data presented by the patient and the diagnostic and treatment options available.
Description of Implementation Strategy
The following clinical audit parameters, based on recommendations in these guidelines, are proposed: Percentage of schizophrenic patients prescribed antipsychotic medication Percentage of schizophrenic patients prescribed clozapine, who are intolerant or unresponsive to other antipsychotic medications Percentage of schizophrenic patients prescribed clozapine, whose full blood count is regularly monitored
Implementation Tools
Clinical AlgorithmForeign Language TranslationsPatient ResourcesFor information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Getting BetterLiving with Illness
IOM Domain
EffectivenessPatient-centerednessSafety
Bibliographic Source(s)
Singapore Ministry of Health. Schizophrenia. Singapore: Singapore Ministry of Health; 2003 Feb. 40 p. [29 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Date Released
2003 Feb
Guideline Developer(s)
Singapore Ministry of Health - National Government Agency [Non-U.S.]
Source(s) of Funding
Singapore Ministry of Health
Guideline Committee
Workgroup on Schizophrenia
Composition of Group that Authored the Guideline
Workgroup Members: A/Prof Chong Siow Ann, Chief, Department of Early Psychosis Intervention, Director of Research, Institute of Mental Health and Woodbridge Hospital (Chairman); Dr Ang Ah Ling, Senior Consultant, Institute of Mental Health and Woodbridge Hospital; Col(Dr) Ang Yong Guan, Chairman of Chapter of Psychiatry, Academy of Medicine, Singapore; Dr Chee Kuan Tsee, Senior Consultant, Institute of Mental Health and Woodbridge Hospital; Dr Lyn Chua, Head, Department of Psychology, Institute of Mental Health and Woodbridge Hospital; A/Prof Calvin Fones, Head, Department of Psychological Medicine, National University Hospital; Dr Leong Oil Ken, Senior Consultant, Institute of Mental Health and Woodbridge Hospital; A/Prof Rathi Mahendran, Chief, Department of General Psychiatry, Director of Training, Institute of Mental Health and Woodbridge Hospital; Dr Francis Ngui, Consultant Psychiatrist, President, Singapore Psychiatric Association, Medical Director, Adam Road Hospital; A/Prof Ong Thiew Chye, Senior Consultant, Department of Psychological Medicine, Tan Tock Seng Hospital; A/Prof Tan Chay Hoon, Consultant Psychiatrist, National University Hospital; Dr Tan Chue Tin, Consultant Psychiatrist, Mount Elizabeth Medical Centre; Dr Tay Woo Kheng, Head, Division of Psychological Medicine, Changi General Hospital; A/Prof Wong Kim Eng, Chairman Medical Board, Institute of Mental Health and Woodbridge Hospital
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
Guideline Availability
Electronic copies: Available in Portable Document Format (PDF) from the Singapore Ministry of Health Web site. Print copies: Available from the Singapore Ministry of Health, College of Medicine Building, Mezzanine Floor 16 College Rd, Singapore 169854.
Availability of Companion Documents
None available
Patient Resources
The following is available: Schizophrenia. Singapore: Singapore Ministry of Health; 2003. 28 p. Electronic copies: Available in Portable Document Format (PDF) from the Singapore Ministry of Health Web site. Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.
NGC STATUS
This summary was completed by ECRI on November 28, 2003. This summary was updated by ECRI on January 18, 2006, following the U.S. Food and Drug Administration advisory on Clozaril (clozapine).
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Please contact the Ministry of Health, Singapore by e-mail at MOH_INFO@MOH.GOV.SG.
NGC Disclaimer
The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx.NGC, AHRQ, and its contractor ECRI make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.Readers with questions regarding guideline content are directed to contact the guideline developer.