Evidence-based pharmacologic treatment for people with severe mental illness: a focus on guidelines and algorithms

Toward Precision Characterization and Treatment of Psychopathology: A Path Forward and Integrative Framework of the Hierarchical Taxonomy of Psychopathology and the Research Domain Criteria

A critical mission of psychological science is to conduct research that ultimately improves the lives of individuals who experience psychopathology. One important aspect of accomplishing this mission is increasing the likelihood that treatments will work for each person. I contend that treatment prognosis can be improved by moving toward a precision-medicine model. I advance a principle-driven framework for working toward these objectives. First, I synthesize the Hierarchical Taxonomy of Psychopathology and the Research Domain Criteria and demonstrate how integrating these models facilitates precision characterization of psychopathology. Second, I outline and demonstrate a systematic process for approaching treatment selection by leveraging precisely characterized representations of psychopathology. Finally, I advocate the research and clinical applications of this framework. Although clinical and psychological scientists are conducting exciting, multidisciplinary, and methodologically rigorous research in their respective domains, the impact of these pursuits will be maximized in the context of a unifying theoretical framework that supports a clear guiding mission.

From QAAPAPLE 1 to QAAPAPLE 2: how do we move from one algorithm to another one with Long Acting Antipsychotics (LAIs)

BACKGROUND

In 2011, the authors published an algorithm summarizing practice guidelines related to the use of long-acting antipsychotics (LAIs) called the Québec Algorithme Antipsychotique à Action Prolongée (QAAPAPLE), and proposed that it be revised every 5-10 years to update it according to most recent scientific knowledge. Therefore, a re-evaluation of the algorithm was conducted to determine which recommendations were still relevant and which needed modification.

METHODS

The authors conducted a two-fold approach: a review of the literature to include new evidence since 2011 (controlled trials, meta-analyses, and practice guidelines); and a participatory component involving electronic surveys, conferences, encounters with opinion leadres, and patients' representatives.

RESULTS

Overall, prescribers tended to make decisions based on personal experience and conversations with colleagues rather than consulting evidence-based guidelines. To test if the algorithm was useful worldwide, it was presented in the United Arab Emirates, where the feedback was in agreement with the algorithm and its limitations.

CONCLUSIONS

Since its initial publication, the QAAPAPLE algorithm has been updated to guide clinicians on the use of LAIs. The new algorithm has also been assessed outside Canada to test its generalizability worldwide, and indicated its flexibility, efficiency, and user-friendliness in order to guide clinicians on the use of LAIs.

What do clinicians treat: Diagnoses or symptoms? The incremental validity of a symptom-based, dimensional characterization of emotional disorders in predicting medication prescription patterns

BACKGROUND

Although practice guidelines are based on disorders specified in diagnostic manuals, such as the DSM, practitioners appear to follow symptoms when making treatment decisions. Psychiatric medication is generally prescribed in a transdiagnostic manner, further highlighting how symptoms, not diagnoses, often guide clinical practice. A quantitative approach to nosology promises to provide better guidance as it describes psychopathology dimensionally and its organization reflects patterns of covariation among symptoms.

AIM

To investigate whether a quantitative classification of emotional disorders can account for naturalistic medication prescription patterns better than traditional diagnoses.

METHODS

Symptom dimensions and DSM diagnoses of emotional disorders, as well as prescribed medications, were assessed using interviews in a psychiatric outpatient sample (N=318, mean age 42.5years old, 59% female, 81% Caucasian).

RESULTS

Each diagnosis was associated with prescription of multiple medication classes, and most medications were associated with multiple disorders. This was largely due to heterogeneity of clinical diagnoses, with narrow, homogenous dimensions underpinning diagnoses showing different medication profiles. Symptom dimensions predicted medication prescription better than DSM diagnoses, irrespective of whether this was examined broadly across all conditions, or focused on a specific disorder and medication indicated for it.

CONCLUSIONS

Psychiatric medication was prescribed in line with symptoms rather than DSM diagnoses. A quantitative approach to nosology may better reflect treatment planning and be a more effective guide to pharmacotherapy than traditional diagnoses. This adds to a diverse body of evidence about superiority of the quantitative system in practical applications and highlights its potential to improve psychiatric care.

The Impact of Mental Illness Stigma on Seeking and Participating in Mental Health Care

Treatments have been developed and tested to successfully reduce the symptoms and disabilities of many mental illnesses. Unfortunately, people distressed by these illnesses often do not seek out services or choose to fully engage in them. One factor that impedes care seeking and undermines the service system is mental illness stigma. In this article, we review the complex elements of stigma in order to understand its impact on participating in care. We then summarize public policy considerations in seeking to tackle stigma in order to improve treatment engagement. Stigma is a complex construct that includes public, self, and structural components. It directly affects people with mental illness, as well as their support system, provider network, and community resources. The effects of stigma are moderated by knowledge of mental illness and cultural relevance. Understanding stigma is central to reducing its negative impact on care seeking and treatment engagement. Separate strategies have evolved for counteracting the effects of public, self, and structural stigma. Programs for mental health providers may be especially fruitful for promoting care engagement. Mental health literacy, cultural competence, and family engagement campaigns also mitigate stigma's adverse impact on care seeking. Policy change is essential to overcome the structural stigma that undermines government agendas meant to promote mental health care. Implications for expanding the research program on the connection between stigma and care seeking are discussed.

Recovery from schizophrenia and the role of evidence-based psychosocial interventions

Recovery is the new vision for mental health services, in which two definitions of recovery dominate. Firstly, recovery is an outcome; research suggests that many people with serious mental illness learn to cope with their disabilities so they can achieve major life goals related to independent living. Secondly, recovery is a process; it reintroduces such important values as hope, empowerment and goal orientation into the service system. Both definitions have data that support its assertions, suggesting that an integration of the two offers the most complete and effective picture of recovery. Psychosocial interventions integrated with psychopharmacological strategies have been shown to most effectively help individuals recover. Effective interventions are those that are evidence based and include, illness management, supported employment, assertive community treatment, services to families and dually diagnosed services.

Evidence-based practices in community mental health: outcome evaluation

In 2003, questions were being raised relating to the lack of evidence-based treatments available in public mental health and whether the use of treatments found effective in research settings would be equally effective in real world situations. In response, one state passed a bill mandating a disease management model of service delivery and the use of evidence-based practices designed to obtain better clinical and functional outcomes, and to maximize the possibility for recovery for adults experiencing a serious mental illness. The purpose of this article is to provide an overview of the re-engineered public mental health system and report on findings of a longitudinal time-series study of the redesigned community mental health system. Findings of the study suggest using evidence-based practices and following a disease management model of mental health service delivery can be effective in real world settings for adults experiencing serious mental health symptoms and functional impairment.

Developing a framework to support shared decision making for youth mental health medication treatment

Medical shared decision making has demonstrated success in increasing collaboration between clients and practitioners for various health decisions. As the importance of a shared decision making approach becomes increasingly valued in the adult mental health arena, transfer of these ideals to youth and families of youth in the mental health system is a logical next step. A review of the literature and preliminary, formative feedback from families and staff at a Midwestern urban community mental health center guided the development of a framework for youth shared decision making. The framework includes three functional areas (1) setting the stage for youth shared decision making, (2) facilitating youth shared decision making, and (3) supporting youth shared decision making. While still in the formative stages, the value of a specific framework for a youth model in support of moving from a client-practitioner value system to a systematic, intentional process is evident.

Views about clinical practice guidelines of the Indian Psychiatric Society: A survey of psychiatrists in India

BACKGROUND

The Indian Psychiatric Society (IPS) constituted a task force on clinical practice guidelines (CPGs) in 2004 to formulate guidelines for management of various psychiatric disorders in the Indian setting. Over the next 4 years (2005-2008), the task force published 4 volumes of guidelines covering most of the psychiatric disorders and issues in special populations. However, till now, nothing is known about the usefulness, awareness and their implementation. This was a preliminary survey to know about the usefulness and awareness of the CPGs of the IPS.

MATERIALS AND METHODS

An email survey was sent to 1100 psychiatrists, of which 107 responded.

RESULTS

Only half of the responders were aware about all the 4 volumes of the guidelines and only 12.7% of the responders had read all the four volumes. About two-thirds of the responders had referred to these guidelines in their clinical practice, either occasionally (46.1%), often (16.7%) or always (2%). Similarly, more than two-thirds of the responders considered these guidelines to be helpful in making day-to-day clinical decisions in their practice, either occasionally (48%), often (19.6%) or always (3.9%). In the open-ended questions, many of the responders discussed their dissatisfaction with these guidelines and gave suggestions as to how these guidelines could be improved.

CONCLUSION

There is need for better dissemination of the guidelines and making recommendations that can be applied in an Indian setting.

Reducing variation in the pharmacologic treatment of schizophrenia: defining acceptable standards of treatment

Clinicians are exhorted to improve the quality of care for patients with schizophrenia by applying evidence-based medication treatment guidelines. Unfortunately, although there are many guidelines, they are all more or less out of date, and their recommendations often are inconsistent, leaving clinicians uncertain about the definition of acceptable standards of care. This paper reviews existing guideline recommendations and recently published research related to two parameters of care: 1) first-line treatment of multiepisode psychosis and 2) the care of treatment-resistant patients. Its purpose is to help clinicians understand the implications of the latest research for the content of schizophrenia guidelines and for the clinical practice they are supposed to inform.

Consumer and family views on evidence-based practices and adult mental health services

Evidence-based practice (EBP) is an important construct in mental health services. Though much has been written about them, there is little in the literature that fully explores consumers' and family members' views regarding EBPs. Using a focus group methodology, this study asked the question "What are consumers' and family member's views of EBPs within the larger context of their mental health service needs and their experiences with the mental health service system?" Results indicate that consumers and families have limited knowledge of EBPs, are generally supportive of EBPs, but have questions and concerns that are grounded in systemic and contextual considerations.

Innovations in mental health services implementation: a report on state-level data from the U.S. Evidence-Based Practices Project

BACKGROUND

The Evidence-Based Practice (EBP) Project has been investigating the implementation of evidence-based mental health practices (Assertive Community Treatment, Family Psychoeducation, Integrated Dual Diagnosis Treatment, Illness Management and Recovery, and Supported Employment) in state public mental health systems in the United States since 2001. To date, Project findings have yielded valuable insights into implementation strategy characteristics and effectiveness. This paper reports results of an effort to identify and classify state-level implementation activities and strategies employed across the eight states participating in the Project.

METHODS

Content analysis and Greenhalgh et al's (2004) definition of innovation were used to identify and classify state-level activities employed during three phases of EBP implementation: Pre-Implementation, Initial Implementation and Sustainability Planning. Activities were coded from site visit reports created from documents and notes from key informant interviews conducted during two periods, Fall 2002-Spring 2003, and Spring 2004. Frequency counts and rank-order analyses were used to examine patterns of implementation activities and strategies employed across the three phases of implementation.

RESULTS

One hundred and six discreet implementation activities and strategies were identified as innovative and were classified into five categories: 1) state infrastructure building and commitment, 2) stakeholder relationship building and communications, 3) financing, 4) continuous quality management, and 5) service delivery practices and training. Implementation activities from different categories were employed at different phases of implementation.

CONCLUSION

Insights into effective strategies for implementing EBPs in mental health and other health sectors require qualitative and quantitative research that seeks to: a) empirically test the effects of tools and methods used to implement EBPs, and b) establish a stronger evidence-base from which to plan, implement and sustain such efforts. This paper offers a classification scheme and list of innovative implementation activities and strategies. The classification scheme offers potential value for future studies that seek to assess the effects of various implementation processes, and helps establish widely accepted standards and criteria that can be used to assess the value of innovative activities and strategies.

The Korean Medication Algorithm for Major Depressive Disorder (KMA-MDD): Report of the Korean Society of Depressive and Bipolar Disorders

Objective. There are many differences in biological characteristics, clinical situations, and medical insurance systems with ethnic groups or countries. The Korean Society of Depressive and Bipolar Disorders decided to develop a Korean treatment algorithm for major depressive disorder. Methods. The Korean Medication Algorithm Project for Major Depressive Disorder (KMAP-MDD) was designed with the following principles: (1) to be an ideal algorithm, (2) to be a Korean algorithm, (3) to be a medication algorithm, (4) to be an evidence-based and formal consensus algorithm. After collecting and reviewing many literature citations and reports by evidence-based rule, we constructed a survey questionnaire for formal consensus of Korean experts. By employing panels of experts to review the evidence and survey results thoroughly, we used evidence-based algorithm development as a component of a formal consensus development process. Results. We developed two algorithms for the KMA-MDD: one for major depressive disorder without psychotic feature and the other for major depressive disorder with psychotic features. Clinical guidelines for the implementation of KMA-MDD were also developed. The KMA-MDD provides specific treatment strategies for each stage. Conclusions. The KMA-MDD is the first Korean algorithm for treatment of major depressive disorder. It is based on evidence which supports the efficacy of each treatment, and it has obtained the consensus of Korean experts. We hope that the KMA-MDD will be good practical tool for clinicians who treat major depressive disorder in Korea.

Lessons learned in implementing evidence-based practices: implications for psychiatric administrators

Factors related to the dissemination and implementation of evidence-based practices (EBPs) are discussed. Extensive effort is required to successfully implement and sustain EBPs that improve clinical outcomes. There is a rapid rate of discovery of new EBPs. Examples of large-scale implementations of EBPs in mental health are described with emphasis on the factors thought critical for success. The need for designing systems which can cost-effectively implement new EBPs is highlighted. Finally, the implications for psychiatric administrators are discussed.

Treatment of epilepsy in adults: expert opinion, 2005

RATIONALE

Over the past decade, there has been a proliferation of new therapies for the treatment of epilepsy. Faced with this growing list of options, clinicians must decide what therapy, or combination of therapies, is best for a given individual. Although controlled clinical trials exist for each treatment option, the answer to these questions may remain unclear. In 2000, a survey of expert opinion was done to address questions concerning which treatment options might be best in a number of clinical situations. We surveyed a group of US epileptologists again in 2004 and compared the results of the two surveys.

METHODS

We sent a questionnaire on the treatment of adolescent and adult epilepsy syndromes to a group of opinion leaders in the field of epilepsy. The questions were formatted to simulate real-world clinical situations in the treatment of symptomatic localization related epilepsy (SLRE) and idiopathic generalized epilepsy (IGE). The experts were asked to rate treatment options based on a modified RAND 9-point scale (with "9" most appropriate and "1" least appropriate). Statistical analysis of data was performed as defined by the expert consensus method. The results were used to develop user-friendly recommendations concerning overall treatment strategies and choice of specific medications.

RESULTS

Of the 48 experts to whom the survey was sent, 43 (90%) responded; 29 (67%) of the respondents had also participated in the first survey. For initial monotherapy for IGE (generalized tonic-clonic [GTC], absence, and myoclonic seizures), valproate was rated as treatment of choice. For IGE-GTC seizures, lamotrigine and topiramate were also identified as usually appropriate for initial monotherapy. For IGE-absence seizures, ethosuximide was also a treatment of choice, and lamotrigine was usually appropriate. For SLRE, the experts were again asked to rate treatment options based on seizure type: simple partial seizures (SPS), complex partial seizures (CPS), and secondarily generalized tonic-clonic seizures (SGTC). In SLRE-SPS and SLRE-SGTC, carbamazepine and oxcarbazepine were treatments of choice, with lamotrigine and levetiracetam also usually appropriate. In SLRE-CPS, carbamazepine, lamotrigine. and oxcarbazepine were treatments of choice, while levetiracetam was also usually appropriate. For women who are pregnant or trying to conceive, lamotrigine was treatment of choice for both syndrome types. In the elderly, whether medically stable or ill, the treatment of choice was lamotrigine, while levetiracetam was also usually appropriate (along with gabapentin for persons with comorbid medical illness). In persons with HIV and epilepsy, lamotrigine and levetiracetam were usually appropriate. In people with both epilepsy syndromes who have depression, lamotrigine was treatment of choice. In a person with seizures and renal disease, lamotrigine was usually appropriate for both syndromes, with valproate also usually appropriate for IGE. In patients with hepatic disease, levetiracetam and lamotrigine were usually appropriate for IGE; in SLRE, levetiracetam was treatment of choice, with gabapentin also usually appropriate.

CONCLUSIONS

Although the panel of experts reached consensus on many treatment options, there are limitations to these types of data. Despite this, the expert consensus method concisely summarizes expert opinion, and this opinion may be helpful in situations in which the medical literature is scant or lacking. The information in this report should be evaluated in conjunction with evidence-based findings.

Diagnosing schizophrenia circa 2005: how and why?

Since the introduction of the third edition of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition in 1980, schizophrenia has been widely diagnosed with good to excellent levels of reliability. This is no small feat, as prior to the 1970s the reliability of this diagnosis over time and place was very poor. Although there have been some changes in the diagnostic algorithm for schizophrenia with subsequent revisions of the Diagnostic and Statistical Manual of Mental Disorders, there has been little change in the overall classification scheme. However, there has also been relatively little movement toward enhancing the validity of this diagnosis. Although there is broad consensus that what we now call schizophrenia is probably very heterogeneous with respect to underlying etiology and pathophysiology, attempts to identify more valid subtypes or dimensions have not progressed to the point that they are likely to be incorporated into diagnostic systems any time soon. The limited progress in defining more valid disease categories has increasingly important clinical implications as the field moves more and more to treatment by preset algorithms that are typically driven by diagnosis.

Genetic study of the myelin oligodendrocyte glycoprotein (MOG) gene in schizophrenia

Schizophrenia (SCZ) is a neuropsychiatric disorder that affects approximately 1% of the general population. The human leukocyte antigen (HLA) system has been implicated in several genetic studies of SCZ. The myelin oligodendrocyte glycoprotein (MOG) gene, which is located close to the HLA region, is considered a candidate for SCZ due to its association with white matter abnormalities and its importance in mediating the complement cascade. Four polymorphisms in the MOG gene (CA)n (TAAA)n, and two intronic polymorphisms, C1334T and C10991T, were investigated for the possibility of association with SCZ using 111 SCZ proband and their families. We examined the transmission of the alleles of each of these polymorphisms with the transmission disequilibrium test. We did not observe significant evidence for biased transmission of alleles at the (CA)n (chi2=2.430, 6 df, P=0.876) (TAAA)n (chi2=3.550, 5 df, P=0.616), C1334T (chi2=0.040, 1 df, P=0.841) and C10991T (chi2=0.154, 1 df, P=0.695) polymorphisms. Overall haplotype analysis using the TRANSMIT program was also not significant (chi2=7.954, 9 df, P=0.539). Furthermore, our results comparing mean age at onset in the genotype groups using the Kruskal-Wallis Test were not significant. Our case-control analyses (182 cases age-, sex- and ethnicity-matched with healthy controls) and combined z-score [(CA)n: z-score=-1.126, P=0.130; (TAAA)n: z-score=-0.233, P=0.408; C1334T: z-score=0.703, P=0.241; C10991T: z-score=0.551, P=0.291] were also not significant. Although our data are negative, the intriguing hypothesis for MOG in SCZ may warrant further investigation of this gene.

Promoting the implementation of practices that are supported by research: the National Implementing Evidence-Based Practice Project

The National Implementing Evidence-Based Practice Project is an ongoing effort to promote the implementation of effective practices for adults who have severe mental illnesses. The project members designed and developed integrated packages of materials and services to help practice sites implement evidence-based practices and is field-testing the approach in eight states. These implementations are being evaluated carefully to learn how to make the technology transfer process more efficient in the future. This article describes the project and provides some early reflections on the implementation experience.

Recovery principles and evidence-based practice: essential ingredients of service improvement

The two of the most commonly advocated service improvement proposals for adults with severe mental illnesses are to redesign services based on recovery principles and to increase the availability of services with strong research support. The two improvement strategies complement and inform each other much more than they conflict. To improve, the field needs the insights of people who have personally experienced severe mental illnesses and it needs the scientific process. Applied together, the two strategies can guide the development of an optimal service system: The kind of service system that most people would want for themselves or their family should they have the need.

Results of a naturalistic longitudinal study of benzodiazepine and SSRI use in the treatment of generalized anxiety disorder and social phobia

The past decade has brought major new developments in the psychopharmacologic management of generalized anxiety disorder and social phobia. We examined medication-prescribing patterns for the treatment of these anxiety disorders for 12 years to assess changes in patients' anti-anxiety psychotropic medication usage during that period of evolving practice guidelines. We examined psychotropic medication use in 305 patients with generalized anxiety disorder and 232 with social phobia enrolled in the Harvard/Brown Anxiety Disorders Research Project (HARP), a prospective, longitudinal study of anxiety disorders. Psychotropic treatment patterns seem to have remained relatively stable over 12 years with benzodiazepines the medications most commonly used for both generalized anxiety disorder and social phobia. Comparatively, selective serotonin reuptake inhibitor (SSRI) and venlafaxine usage as stand-alone medications for these disorders remained low throughout the follow-up period. At the 12-year follow-up, 24% of patients with generalized anxiety disorder and 30% of patients with social phobia were utilizing neither an SSRI/selective norepinephrine reuptake inhibitor (SNRI) nor a benzodiazepine. Treatment recommendations for use of SSRIs and venlafaxine in the management of generalized anxiety disorder and social phobia initially promulgated in 1998 had a modest impact on changes in psychopharmacologic practice 4-5 years later. Difficulties in the implementation of treatment guidelines are discussed.

How evidence-based practices contribute to community integration

Since the groundbreaking work of the Robert Wood Johnson Conference in 1998 identifying six evidence-based practices (EBPs) for people with severe mental illness (SMI), the mental health field has moved in the direction of re-examination and redesign of service systems. Surprisingly, one area that has not been fully explicated is the role that EBPs play in promoting community integration. In this paper, we explain how community integration is a unifying concept providing direction and vision for community mental health for people with SMI. As one crucial aspect of the recovery process, community integration clarifies the link between EBPs and recovery. We propose an alternate view, grounded in the empirical literature, to the assertion by Anthony, Rogers, and Farkas [2003, Community Mental Health Journal, 39, 101-114] that "EBP research has rarely demonstrated a positive impact on recovery related outcomes."

What is evidence?

The evidence-based practice movement rests on the premise that the scientific evidence regarding treatment should be used judiciously to inform treatment decisions. This article focuses on the most fundamental question regarding evidence-based practice: What is evidence? To address this question, the authors first review several of the definitions, criteria, and strategies that have been used to define scientific evidence. Second, a number of critical issues that have been raised regarding the nature of treatment evidence are discussed. Finally, suggestions for further consideration in the process of synthesizing evidence for clinicians are offered.

Evidence-based practices: setting the context and responding to concerns

After nearly 20 years of progress in general medicine, the evidence-based practice movement is becoming the central theme for mental health care reform in the first decade of 2000. Several leaders in the movement met to discuss concerns raised by six stakeholder groups: consumers, family members, practitioners, administrators, policy makers, and researchers. Recurrent themes relate to concerns regarding the limits of science, diversion of funding from valued practices, increased costs, feasibility, prior investments in other practices, and shifts in power and control. The authors recommend that all stakeholder groups be involved in further dialog and planning to ensure that practices emerge that represent the integration of the best research evidence with clinical expertise and consumer values.

Public policy and evidence-based practice

The time has come to add to the body of EBP implementation knowledge at multiple levels, including knowledge about policy, program priorities, clinician practice, consumer adherence, and family member support. Implementation at the policy level, however, is primary and paramount. The national initiative supporting EBP implementation is one of the most important innovations on the mental health horizon. It will serve as the testing ground for what can be learned about bridging the gap between science and service. This important initiative will not go far if it is not supported by mental health policies--at state and federal levels--that create the organizational and financial incentives to implement EBPs. In addition, it will be a time-limited activity if it also does not yield lessons about how to adapt to new evidence and on-going systemic changes. Organizations must be flexible and able to learn and adapt. The promise of decades of research must be realized in practice. There is an opportunity to combine quality improvement with accountability through performance measurement and the implementation of effective new services and treatments. The Surgeon General simultaneously identified this research's promise and documented its shortcomings. His report outlines courses of action for policymakers that should guide clinicians away from service disparities and toward the implementation of EBP.

The history of community mental health treatment and rehabilitation for persons with severe mental illness

The authors review the evolution of the treatments for persons with severe mental illnesses over the past 40 years in three areas: pharmacological and other somatic treatments, psychosomatic treatments, and rehabilitation. Current treatments are based on a much stronger evidence base, are more patient-centered, and are more likely to target autonomy and recovery.

Clinical practice variations in prescribing antipsychotics for patients with schizophrenia

Few studies have examined the variations among individual physicians in prescribing antipsychotics for schizophrenia. This study examined clinical practice variations in the route and dosage of antipsychotic medication prescribed for inpatients with schizophrenia by 11 different psychiatrists. The sample consisted of 130 patients with a DSM-III-R diagnosis of schizophrenia who had received inpatient care at a state hospital or Veterans Affairs medical center in the southeastern United States in 1992-1993. Mixed-effects regression models were developed to explore the influence of individual physicians and hospitals on route of antipsychotic administration (oral or depot) and daily antipsychotic dose, controlling for patient case-mix variables (age, race, sex, duration of illness, symptom severity, and substance-abuse diagnosis). The average daily antipsychotic dose was 1092 +/- 892 chlorpromazine mg equivalents. Almost half of the patients (48%) were prescribed doses above or below the range recommended by current practice guidelines. The proportion of patients prescribed depot antipsychotics was significantly different at the 2 hospitals, as was the antipsychotic dose prescribed at discharge. Individual physicians and patient characteristics were not significantly associated with prescribing practices. These data, which were obtained before clinical practice guidelines were widely disseminated, provide a benchmark against which to examine more current practice variations in antipsychotic prescribing. The results raise several questions about deviations from practice guidelines in the pharmacological treatment of schizophrenia. To adequately assess quality and inform and possibly further develop clinical practice guideline recommendations for schizophrenia, well-designed research studies conducted in routine clinical settings are needed.

Integrated care in schizophrenia: a 2-year randomized controlled study of two community-based treatment programs

OBJECTIVE

To evaluate the efficacy of two community-based programs that combined antipsychotic medication, family interventions and social skills training.

METHOD

A randomized controlled trial with 2 years follow-up. The study included 84 patients with schizophrenic disorders, continuously managed in terms of care and treatment, and regularly assessed. Analysis was by intention-to-treat.

RESULTS

Between-program comparisons showed significantly improved social function and consumer satisfaction in favour of the program 'Integrated Care' (IC) at the 2-year follow-up. The main clinically important differences between the two treatment programs studied were the procedures for shared decision making and patient empowerment in IC.

CONCLUSION

The implementation of IC in clinical practice can improve social recovery and increase consumer satisfaction for patients with schizophrenic disorders. We identified specific procedures that might be added to improve the effectiveness of any program for severely mental ill people.

Pharmacologic treatment of schizophrenia: what the future holds

The advent of the newer "atypical" antipsychotics has revolutionized pharmacologic treatment of schizophrenia (SZ) and other psychotic disorders. In contrast to the first-generation conventional neuroleptics, these second-generation antipsychotic agents possess a broader spectrum of efficacy and cause fewer motor side effects such as extrapyramidal symptoms and tardive dyskinesia. Despite their substantial advantages, however, these second-generation agents also have significant limitations in terms of both efficacy and adverse effects. Several strategies to address these shortcomings are currently under study and some of these are likely to become part of our therapeutic armamentarium in the future. Current shortcomings in the pharmacologic treatment of SZ and strategies under investigation to address each of these deficiencies are reviewed. New formulations of existing medications and new antipsychotics under development are discussed. Developing adjunctive treatment strategies to address each of the major psychopathologic domains in SZ are summarized. The potential application of genetic information to treatment-matching in SZ is reviewed and likely refinements in the practice of evidence-based medicine in the pharmacotherapy of SZ are considered.