Clinical Practice Guidelines for Management of Schizophrenia

Abstract

Participants of expert group on CPG for Schizophrenia B.N. Gangadhar, P.K. Dalal, Lalit Batra, Kishore Gujar, O.P Singh, Bharat Singh, Abhay Matkar, Devendra Vijayvargiya, R.K. Solanki, Adarsh Tripathi INTRODUCTION Schizophrenia is a serious mental disorder with prevalence rates of 2-3 per 1000 reported from India. The impact of schizophrenia on patients, their families and the wider society are no different from what has been observed in the rest of the world. However, resource constraints, poverty, lack of education and inadequate access to health care facilities for patients make the problem of providing care particularly daunting in India. In 2005, the Indian Psychiatric Society came up with treatment guidelines for schizophrenia tailored to meet the requirements of our patients in the context of prevailing existing resources. There have been several developments in the management of schizophrenia since then. These new set of guidelines attempt to update the previous guidelines by emphasizing what is new in the field. These guidelines ought to be read in conjunction with the earlier version of the treatment guidelines on schizophrenia as developed and published by the Indian Psychiatric Society in the year 2005. SCOPE OF THIS DOCUMENT The major emphasis of the current guidelines is on areas in the management of schizophrenia, which have witnessed significant developments since the publication of the previous guidelines. These guidelines are not particularly applicable to any specific treatment setting and may need minor modifications to suit the needs of patients in a specific setting. The recommendations are primarily meant for adult patients. The needs of children or the elderly with schizophrenia may be different. Finally, it is expected that recommendations made will have to be tailored to suit the needs of individual patients. Assessment and evaluation (table-1)Table 1: Components of assessment and evaluationA comprehensive assessment of the patient and his/her caregivers needs to be carried out. The cornerstone of this assessment is a detailed history and physical and mental state examinations. Efforts should be made to obtain information from all sources, especially the family. Wherever possible, diagnosis of schizophrenia be preferably made according to current diagnostic criteria, as such a diagnosis is more reliable. A reliable diagnosis facilitates communication among clinicians, and allows for better applicability of evidence-based recommendations. Many clinical conditions that may mimic schizophrenia include mood disorders, substance-induced psychoses and psychoses secondary to physical illnesses. These should be ruled out as far as possible by history, examination and additional investigations. In some instances a definitive diagnosis may need time. Further, because of the enormous psychosocial consequences a diagnosis of schizophrenia needs to be made with great caution and sensitivity. In doubtful cases, a medication-free observation period can be considered. However, consideration of medication free period need to be balanced against the risks of delaying treatment or the potential for harm to self and others in acutely ill patients. It is important to remember that diagnosis is not a one-time affair, but a continuous process. Accordingly, based on the subsequent information from patients and caregivers, and on repeated clinical evaluations the diagnosis may need re-evaluation. The assessment should cover all other areas such as symptom dimensions, symptom-severity, comorbid psychiatric and medical conditions, particularly comorbid substance abuse, the risk of harm to self or others, level of functioning and the socio-cultural milieu of the patient. A high index of suspicion along with thorough assessment can help in detecting most patients with comorbid substance abuse/dependence. Wherever, facilities are available, urine or blood screens (with prior consent) can be used to confirm the presence of comorbid substance abuse/dependence. A thorough physical examination need to be done to rule out presence of any physical illness and also to rule out psychoses secondary to physical illnesses. This may be supplemented by the judicious use of investigations. Wherever possible, unstructured assessments need to be supplemented by ratings on appropriate standardized rating scales. Other options such as detailed cognitive testing can be done if required and feasible. The use of neuroimaging may be indicated in those with first-episode psychosis, neurological signs, non-response to treatment and elderly patients. Assessments of caregivers may focus on areas such as their knowledge and understanding of the illness, their attitudes and beliefs regarding treatment, the impact of the illness on them and their personal and social resources. It is important to remember that assessment is an ongoing process. As the treatment progresses other areas such as response to treatment, side effects, treatment ad