Antipsychotic treatment algorithm for first episode schizophrenia – a guide for clinicians
Ofer Agid1,2, Gagan Fervaha1, Robert Zipursky3, Hiroyoshi Takeuchi1, Foussias Gorge1,2, Huma Shireen1, Gary Remington1,2; 1Centre for Addiction and Mental Health, Toronto, Canada, 2University of Toronto, Faculty of Medicine, Toronto, Canada, 3Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
Clinicians treating first-episode schizophrenia are faced with numerous choices in terms of antipsychotic, dose, formulation, etc. In addition, assessing response can be difficult due to lack of clarity regarding definition of response, remission, and the appropriate time to achieve each. We developed a treatment algorithm for first-episode schizophrenia using standardized clinical rating scales to evaluate response. The algorithm assumes that early and effective disease management may favorably influence outcome. Further assumptions include: early onset of action of antipsychotics; treatment resistant schizophrenia (TRS) can be identified during the earliest stages; and relapse prevention efforts should be implemented as soon as possible. The algorithm progresses according to response, moving patients through two non-clozapine second generation antipsychotic (SGA) trials followed by clozapine. Patients achieving response are advised to switch to SGA-long acting injectable (LAI) formulations. 457 patients were offered treatment according to the algorithm, of these, 338 (74%) commenced treatment and completed at least one antipsychotic trial. At 6-month antipsychotic treatment was: oral SGA 154 (45.6%); LAI 100 (29.5%); clozapine 79 (23.3%); FGA/Polypharmacy 5 (1.5%). We provide findings from an established algorithm that is evidence based and addresses practical issues often not captured by randomized clinical trials (RCTs). Our own experience indicates that approximately 50% will be treated with an oral SGA, 30% with a LAI SGA, and 20% with clozapine. This distribution might serve as an index for good clinical practice in first-episode schizophrenia clinics.
Topic Area: First Episode Psychosis