Evidence-Based Guidelines for Management of Schizophrenia
Schizophrenia is a complex psychiatric illness presenting with complex symptomatology that affects personal behavior, thinking, speech, memory, and social interactions. The adverse events associated with schizophrenia negatively affect the quality of life and increase the risk of suicide, stigmatization, and poor social interactions secondary to disorganized behaviors (Weiss et al., 2019). Treating and managing patients can be achieved by non-pharmacologic, pharmacologic, or a combination of both.
However, there is always a dilemma regarding the appropriate intervention for specific symptoms, as various symptoms respond to specific modalities. Amidst this uncertainty, reference to evidence-based practice (EBP) guidelines is mandated. EBP guidelines provide essential information based on information gathered from reputable databases, including MEDLINE, Google Scholar, PsycInfo, and PubMed. These databases provide information from peer-reviewed sources, clinical practice trials, systematic reviews, clinical guidelines, and expert opinions.
The EBP information from these various sources is essential in helping healthcare providers make correct decisions regarding the choices for managing patients to attain beneficial health effects. Using EBP guidelines enhances health outcomes and improves the quality of life (Keepers et al., 2020). Therefore, every healthcare provider must review the available guidelines while managing patients with schizophrenia. This paper presents a review of the EBP guideline for the management of schizophrenia. The contents will be presented in multiple subheadings, as presented below.
Who were the guideline developers?
This guideline was developed through a collaboration of Australian and New Zealand experts in the management of schizophrenia. Experts were derived from various sectors, including universities, mental health hospitals, and clinical research centers, with fifteen organizations represented in this clinical guideline. Individual members drafted sections according to their area of interest and expertise with reference to existing literature reviews and systematic reviews.
Were the developers of the guideline representative of key stakeholders in this specialty (interdisciplinary)?
The stakeholders in the development of this guideline were representatives of various disciplines in psychiatry. The participants were experts in the management of schizophrenia and related disorders. The group consisted of clinicians and professors from various psychiatric departments, rehabilitative services, mental health and addiction services, and the center for clinical research in Neuropsychiatry.
In addition, a total of 11 experts, either on a clinical or academic level, provided feedback on the guidelines. During the consultation phase, fellows and trainees from the Royal Australian and New Zealand College of Psychiatrists (RANZCP), professional bodies, and career groups were included.
Who funded the guideline development?
Funding was majorly facilitated by the Royal Australian and New Zealand College of Psychiatrists (RANZCP).
Were any of the guideline developers funded researchers of the reviewed studies?
Various publications by guideline developers were reviewed to develop this guideline. The research contributed to the enormous amount of information that helped create this current clinical guideline.
Did the team have a valid development strategy?
A clear and valid development strategy was used during the development of the guideline. First, the consensus group to provide expert knowledge was identified. Every expert drafted areas according to their interest and area of expertise using the existing research literature and reviews.
The Australian National Health and Medical Research Council guideline was used to classify the levels of evidence. The entire working group also considered the relevant international clinical guidance practice. Furthermore, the roles and contributions of every stakeholder were clearly stated.
Was an explicit (how decisions were made), sensible, and impartial process used to identify, select, and combine evidence?
Decisions to include evidence were unanimously arrived at by all members involved. The experts first identified and drafted the evidence based on their interests. Evidence-based recommendations (EBRs) were formulated when the working group found sufficient evidence on the topic. This helped classify evidence into different levels and ensure articles with high-level evidence were included.
In case the identified evidence was weak or lacking, consensus-based recommendations (CBRs) were formulated. CBRs allowed for the creation of consensus within the expert group was reached based on their collective clinical experience and research knowledge.
Furthermore, after developing the manuscript, the whole working group reviewed the manuscript and held discussions through a series of teleconferences. This allowed members to hold open discussions to reach a consensus in case of a disagreement on the interpretation of evidence or clinical advice.
Besides, a team of 11 experts in schizophrenia from Australia and New Zealand provided feedback which the writing group used to revise the manuscript. Further consultations were made with fellows and trainees of RANZCP, professional bodies, and special interest groups to help identify gaps and provide further comments to improve the guideline.
Did its developers carry out a comprehensive, reproducible literature review within the past 12 months of its publication/revision?
The developers undertook a rigorous process to identify appropriate articles published within a year. For example, recent international clinical practice guidelines such as the UK National Institute for Health and Care Excellence (NICE) guideline in treating psychosis and schizophrenia in adults were used. In addition, the World Federation of Societies of Biological Psychiatry guidelines was used. Most articles published within the last 5 years were included in the review.
Were all important options and outcomes considered?
The guideline considered all the options and outcomes. The treatment options for schizophrenia were classified based on the staging of patients. Treatment options under consideration were pharmacologic and non-pharmacologic treatment. Pharmacologic treatment majorly involves the various classes of antipsychotic medications broadly classified as first-generation and second-generation antipsychotics (Grover & Avasthi, 2019).
Other medications included benzodiazepines, mood stabilizers, and omega-3-fatty acids. The discussion provided a scenario of when to use these medications, including their effectiveness, side effects, and how to overcome/prevent them. The side effects of antipsychotics included extra-pyramidal effects such as acute dystonia, akathisia, tardive dyskinesia, and parkinsonism.
On the other hand, the non-pharmacologic treatments addressed included electro-convulsive therapy, neurostimulation, psychoeducation, family support, cognitive behavioral therapy, social cognition therapy, and vocational rehabilitation. The guideline also included treatment options for specialized groups with schizophrenia, such as children, the elderly, and pregnant women. Besides, outcomes for schizophrenia were discussed in terms of comorbidities, trauma, suicide, and risk of death.
Is each recommendation in the guideline tagged by the level/strength of evidence upon which it is based and linked to the scientific evidence?
The recommendations are backed by substantial evidence. The articles used were grouped into different levels of evidence to back the recommendations. The Australian National Health and Medical Research Council was used to classify the evidence into various levels. For example, level I is a systematic review of level II evidence; level II was the randomized control trials; level III-1 pseudo-randomized control trial; level III-2 is a comparative study with concurrent trial; level III-3 comparative study without concurrent controls, and level IV is a case series with either post-test or pre-test/post-test outcomes. All these levels of evidence were used to make recommendations regarding the treatment options for schizophrenia.
Generally, non-pharmacologic interventions were recommended for early disease, while a combination of both pharmacologic and non-pharmacologic interventions would be suited for severe disease. However, heuristic decision-making of the health provider to decide on the intervention is paramount in people with schizophrenia.
Do the guidelines make explicit recommendations (reflecting value judgments about the outcomes)?
The guidelines recommend early diagnosis and early intervention of patients with schizophrenia. Additionally, the guidelines for respect for patients with schizophrenia as well as offering them equal opportunity to access care. The provision of quality care through enhanced collaboration and the use of evidence-based knowledge can improve health outcomes as the as improve the quality of life of patients with schizophrenia and related disorders.
Has the guideline been subjected to peer review and testing?
Several amendments were made, and the final draft was sent to the RAZNCP for approval. The approved draft was then sent to the Australian and New Zealand Journal of Psychiatry (ANZJP) for peer revision and publication. No further details have been provided about testing.
Is the intent of use provided (i.e., national, regional, local)?
The guidelines provided recommendations for the clinical management of schizophrenia and related disorders for health professionals in Australia and New Zealand. The intended healthcare providers for this guideline include psychiatrists, residential medical officers, psychiatry trainees, general practitioners, hospital interns, and other clinicians working with people suffering from schizophrenia and related psychoses.
The scope of the guidelines is the schizophrenia spectrum, including schizoaffective disorder, schizophrenia, schizophreniform disorder, schizotypal disorder, and transient psychotic disorder with symptoms of schizophrenia.
Are the recommendations clinically relevant?
The recommendations are clinically relevant in several ways. First, the recommendations were developed through the consensus of a group of Australian and New Zealand experts whose experience and practice in the management of schizophrenia and related disorders were unmeasurable. Not only were their decisions guided by literature from research and consensus-based recommendations but also their collective clinical and research knowledge and experience.
Additionally, the use of evidence-based recommendations to judge the sufficiency of the evidence on the topic. These factors ensured that the best evidence was used in developing these guidelines. Furthermore, the recommendations explicitly discuss the different treatment options, including pharmacologic and non-pharmacologic treatment. The extensive literature search included finding the pros and cons of various options, including when they are applicable or not in the management.
The recommendations also provided the various spectrum of schizophrenia and different treatment options. The various spectrum for application of this guideline included ultra-high-risk syndromes, first-episode psychoses, and prolonged psychoses. The guidelines further recommend providing a holistic care approach while addressing all aspects of care for patients with schizophrenia, emphasizing early diagnosis, relief of symptoms, and enhancing optimal recovery of social functions. These recommendations are based on the best literature hence relevant to clinical practice.
Will the recommendations help me in caring for my patients?
I do not doubt that the recommendations of this guideline are well thought out and employ an extensive literature search that makes them relevant to my practice. These recommendations provide information about non-pharmacologic and pharmacologic interventions when caring for patients with schizophrenia. Following the guidelines will help improve my ability to make decisions appropriately according to patient concerns.
In addition to providing early and appropriate interventions, the interventions will also focus on improving physical health, psychosocial treatments, vocational treatment, and observing cultural considerations when providing care as stated in the guidelines. Furthermore, I will be able to respect patients as well as enhance a collaborative approach using evidence-based treatment to offer treatment that addresses specific patient needs.
Are the recommendations practical/feasible? Are resources (people and equipment) available?
The recommendations provided in this guideline are feasible. The broader range of options provided in this guideline means that healthcare providers can always assess the needs of their patients and classify the patient accordingly. They can choose the appropriate options ranging from pharmacologic and non-pharmacologic. My institution takes pride in hiring and retaining healthcare providers with proficient skills and knowledge in handling various conditions.
Many healthcare workers have undergone special pieces of training on matters of mental health. In the past, they have provided care using various guidelines to care for patients. Furthermore, they are always motivated to adopt and use evidence-based knowledge to better patient care. I believe they will be ready to adopt the contents of this guideline to provide care. The organization will provide funds and other resources.
Are the recommendations a major variation from current practice? Can the outcomes be measured through standard care?
These recommendations align with the current guidelines and add more knowledge to the current practice. The use of non-pharmacologic and pharmacologic treatment of schizophrenia helps address various patient concerns (Keepers et al., 2020). Incorporating this knowledge and the current practice will improve decision-making in healthcare, hence improving patient outcomes. The guideline also affirms the provision of standard care through collaborative, respectful, and evidence-based treatment to address specific patient needs.
Grover, S., & Avasthi, A. (2019). Clinical practice guidelines for the management of schizophrenia in children and adolescents. Indian Journal of Psychiatry, 61(Suppl 2), 277–293. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_556_18
Keepers, G. A., Fochtmann, L. J., Anzia, J. M., Benjamin, S., Lyness, J. M., Mojtabai, R., Servis, M., Walaszek, A., Buckley, P., Lenzenweger, M. F., Young, A. S., Degenhardt, A., Hong, S.-H., & (Systematic Review). (2020). The American psychiatric association practice guideline for the treatment of patients with schizophrenia. The American Journal of Psychiatry, 177(9), 868–872. https://doi.org/10.1176/appi.ajp.2020.177901
Weiss, A., Hussain, S., Ng, B., Sarma, S., Tiller, J., Waite, S., & Loo, C. (2019). Royal Australian and New Zealand College of Psychiatrists professional practice guidelines for the administration of electroconvulsive therapy. The Australian and New Zealand Journal of Psychiatry, 53(7), 609–623. https://doi.org/10.1177/0004867419839139