First-Episode Schizophrenia Approaches Aided by Guidelines Instrument

Clinical practice guidelines are important resources for early intervention in a first episode of schizophrenia.

Clinical practice guidelines are important resources for early intervention in a first episode of schizophrenia, but practitioners must have confidence in the quality of the guidance in order to make the correct recommendations, a BMJ study reported.1

Because patients with a first episode of schizophrenia (FES) tend to be more sensitive to the effects of antipsychotic medication and more vulnerable to adverse effects than patients with later-onset episodes, specific guidelines addressing their pharmacologic treatment are required. Using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument, researchers identified and assessed the quality of clinical practice guidelines and developed a list of key health questions relative to FES treatment.

A multidisciplinary group that included psychiatrists, pharmacists, and nurses examined guidelines culled from PubMed and EMBASE databases. The initial search was conducted for guidelines published between January 2009 and April 2016 that contained recommendations in the pharmacologic treatment of adults experiencing an FES. Since an individual’s experience of initial treatment can have implications for future engagement, treatment adherence, and outcome, the key study questions focused on the following areas: initial presentation, maintenance of remission, and treatment resistance.

The AGREE II instrument contained 23 items grouped into 6 “domains”: scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, and editorial independence.2 The items were rated from 1 (strongly disagree) to 7 (strongly agree), with domain scores scaled between 0% and 100%. Three reviewers then used the domain scores to assess overall acceptability of the guidelines with the purpose of informing pharmacologic treatment of FES.

The search strategy identified 3299 records, which were screened and led to the inclusion of 10 guidelines for incorporation into the analysis. The domain scores for scope and purpose were generally high, scoring >80% (range 50% to 100%), for all but one guideline.3 Stakeholder involvement saw wider variation, ranging from 20% to 90%, while the rigor of development domain varied in quality from 41% to 91%. Clinical practice guidelines typically scored high for clarity of presentation (ranging from 52% to 96%), while the applicability domain had a much wider variability (from 14% to 79%). Editorial independence scored between 25% and 97%.

The reviewers generally approved of the guidelines: 3 were recommended for use as written, 6 guidelines required minor modifications, and 1 was not recommended.

Clinical practice guidelines can inform medical decision-making, but target users must assess their quality in order to have confidence in the recommendations. “Using the AGREE II tool helps to identify guidelines that have a transparent, systematic method of development,” said Dolores Keating, head of pharmacy at Saint John of God Hospital in Dublin, Ireland. “Deficiencies in the evidence base make it difficult to address the key health questions relevant to medicine’s optimization in clinical practice. Further research is required to guide choice and dose of medication, duration of treatment, and the management of treatment resistance.”

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  1. Keating D, McWilliams S, Schneider I, et al. Pharmacological guidelines for schizophrenia: a systematic review and comparison of recommendations for the first episode [published online January 6, 2017]. BMJ.
  2. AGREE Next Steps Consortium. Appraisal of guidelines for research & evaluation II. AGREE II Instrument The AGREE Research Trust. 2009.  Accessed January 18, 2017.
  3. Osser DN, Roudsari MJ, Manschreck T. The psychopharmacology algorithm project at the Harvard South Shore Program: an update on schizophrenia. Harv Rev Psychiatry. 2013;21:18-40.