Review
Antipsychotic treatment for schizophrenia in the maintenance phase: A systematic review of the guidelines and algorithms

https://doi.org/10.1016/j.schres.2011.11.021Get rights and content

Abstract

Objective

Antipsychotic treatment strategy for the maintenance phase of schizophrenia has been inconsistent in the literature. The purpose of this systematic review is to overview recommendations in various guidelines and algorithms.

Methods

The guidelines and algorithms for schizophrenia that were published or updated in English after 2000 were searched, using Medline, PubMed, EMBASE, and PsycINFO with the following key words: guideline, algorithm, schizophrenia, and psychosis (last search: July 2011). The reference lists of the relevant reports were also examined.

Results

Fourteen guidelines and algorithms were identified; only five of them clearly defined terms about the maintenance phase and treatment. Ten of 11 guidelines and algorithms did not recommend discontinuation of antipsychotics within five years; six of them partially recommended antipsychotic discontinuation for patients with first-episode schizophrenia exclusive. All nine guidelines and algorithms that referred to intermittent or targeted antipsychotic strategy endorsed against this strategy. Although being a hot topic of controversy, dose reduction of antipsychotics or lower dose therapy in the maintenance phase compared to the acute dosage is not recommended on the whole concerning atypical antipsychotics, whereas dose reduction appears sometimes considered acceptable for typical antipsychotics.

Conclusion

What constitutes maintenance phase and its treatment in schizophrenia has not yet been established in the literature. While discontinuation and intermittent or targeted strategies are not generally recommended, there is controversy regarding dose reduction or lower dose therapy, especially with regards to atypical antipsychotics. Further evidence is needed in order to derive treatment recommendations on antipsychotics in this critical treatment phase of schizophrenia.

Introduction

Antipsychotics play an important role in the management of patients with schizophrenia in that they are indispensable for not only relieving psychotic symptoms in the acute phase (Leucht et al., 2009a, Leucht et al., 2009b) but also preventing relapse in the maintenance phase (Leucht et al., 2003). Therefore, patients with schizophrenia as a rule undergo long-term antipsychotic treatment in order to maintain stability.

Various guidelines and algorithms have been developed regarding psychopharmacological treatment of schizophrenia in an effort to take advantage of accumulating evidence so that it can be better translated into actual clinical practice. For instance, a recent trial in Germany has shown that guideline implementation increased the rate of antipsychotic monotherapy and decreased the incidence of neurologic side effects in a significant manner (Weinmann et al., 2008). In general, in the acute phase of treatment, guidelines and algorithms do not differ very much in their context (Gaebel et al., 2005, Moore, 2011) since they base their recommendations on the similar evidence that is composed of influential double-blind randomized controlled trials or meta-analyses. However, in contrast to acute treatment, the guidelines and algorithms are more diverse regarding maintenance treatment (Bhanji and Tempier, 2002) because there is less evidence available to base the recommendations. Furthermore, the concept of “maintenance treatment” includes various strategies that could reflect treatment needs in chronic phase of the illness; namely antipsychotic discontinuation, intermittent antipsychotic treatment, and antipsychotic dose reduction.

The purpose of this systematic review is to overview various guidelines and algorithms on psychopharmacological treatment for patients with schizophrenia, to highlight management issues with antipsychotics in the maintenance phase of the illness.

Section snippets

Methods

Guidelines and algorithms for schizophrenia that were published or updated after 2000 were searched, using Medline, PubMed, EMBASE, PsycINFO with the following key words: “guideline(s), algorithm(s)” combined with “schizophrenia/schizophrenic, psychosis/psychotic”. The reference lists of the relevant reports were also examined. Last search was conducted on July 2011. Our literature search was limited to publications in English.

Each guideline or algorithm was first evaluated in terms of

Results

Fourteen guidelines and algorithms were identified; their brief summaries are provided in Table 1.

Discussion

This systematic review evaluated psychopharmacological strategies in the maintenance phase of schizophrenia described in the guidelines and algorithms and represents the first work of this sort to the best of our knowledge. It was firstly found that there has been no explicit consensus on the definitions of maintenance phase (Bhanji and Tempier, 2002), making interpretation of treatment recommendations in that stage complicated. Although it is true that the definition of “acute”,

Role of funding source

None.

Contributors

H.T. conceptualized this review, conducted systematic literature search and first drafted the manuscript (under a supervision of T.S.). All authors have significantly contributed to the subsequent revisions for intellectual input and approved to submit the final version of the manuscript.

Conflict of interest

Dr. Takeuchi has received speaker's honoraria or manuscript fees from Dainippon Sumitomo Pharma, Eli Lilly, GlaxoSmithKlein, Janssen Pharmaceutical, and Otsuka Pharmaceutical within the past 5 years.

Dr. Suzuki has received fellowship grants from the Japanese Society of Clinical Neuropsychopharmacology, Government of Canada Post-Doctoral Research Fellowships, Kanae Foundation and Mochida Memorial Foundation, and manuscript fee from Dainippon Sumitomo Pharma and Kyowa Hakko Kirin, and speaker's

Acknowledgment

None

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