In December 2019, the American Psychiatric Association (APA) Board of Trustees approved updated practice guidelines for the treatment of schizophrenia. The last full APA practice guideline was published in 2004, with an update in 2009. The 2019 guidelines aim to improve care quality and treatment outcomes for patients with schizophrenia.  

The lifetime prevalence of schizophrenia is approximately 0.7%, though estimates vary across study populations. Schizophrenia is associated with significant morbidity and early mortality. Between 4 and 10% of patients with schizophrenia are estimated to die by suicide, with rates highest among young men in the early stages of disease. Clinical practice guidelines were developed to reduce the significant disease burden among patients with schizophrenia.     

Clinical practice guidelines were developed using systematic review data of the current scientific literature. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to describe the quality of evidence supporting each proposed guideline. Guidelines were also graded based on investigator certainty that the benefits of the statement outweighed the harms. Recommendations with high evidence quality and investigator certainty are described herein. Guideline statements are classified into 3 categories: (1) initial assessment and treatment plan; (2) pharmacotherapy; (3) and psychosocial treatment.

Initial Assessment and Treatment Plan


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  • The initial assessment of a patient with a possible schizophrenia-spectrum disorder should include an assessment of patient symptoms; patient preferences and goals for treatment; patient symptom and trauma history; patient tobacco and substance use; psychosocial and cultural circumstances; and risk for suicide attempt. A physical and cognitive assessment should also be performed.
  • The initial assessment should use a quantitative measure to determine symptom severity and impairment level.  
  • Patient treatment plans should be comprehensive, well-documented, and incorporate evidence-based nonpharmacological and pharmacological treatments.  

Pharmacotherapy

  • Patients with schizophrenia should receive an antipsychotic medication. During treatment, patients should be closely monitored for drug efficacy and adverse events.
  • Patients who improve with antipsychotic treatment should continue to receive an antipsychotic medication.
  • Patients with treatment-resistant schizophrenia may best benefit from clozapine.
  • Patients with high risk for suicide attempts may best benefit from clozapine treatment over other antipsychotic medications.
  • Patients with acute dystonia associated with antipsychotic treatment should receive an anticholinergic medication.
  • Patients with moderate to severe tardive dyskinesia associated with antipsychotic treatment should receive treatment with a reversible inhibitor of the vesicular monoamine transporter 2 (VMAT2).

Psychosocial Treatment

  • Patients presenting with first episode psychosis should be treated in a coordinated specialty care program.
  • Patients with schizophrenia should be treated with cognitive behavioral therapy for psychosis (CBTp).
  • Patients with schizophrenia should receive psychoeducation.
  • Patients with schizophrenia should receive employment support services.
  • Patients with a history of difficulty engaging in treatment should receive community-based services that enhance compliance.

These practice guidelines provide an overview of appropriate care standards for patients with schizophrenia. Guidelines are based on strong quantitative and qualitative evidence put forth in the literature. While care recommendations will continue evolve with the literature, the present APA guidelines represent best efforts to guide schizophrenia care.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry.

Please see the original reference for a full list of authors’ disclosures.

Reference

Keepers GA, Fochtmann LJ, Anzia JM, et al. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. Am J Psychiatry. 2020;177(9):868-872.