RESUMEN
BACKGROUND: A panel of academic psychiatrists and pharmacists, clinicians from the Texas public mental health system, advocates, and consumers met in June 2006 in Dallas, Tex., to review recent evidence in the pharmacologic treatment of schizophrenia. The goal of the consensus conference was to update and revise the Texas Medication Algorithm Project (TMAP) algorithm for schizophrenia used in the Texas Implementation of Medication Algorithms, a statewide quality assurance program for treatment of major psychiatric illness. METHOD: Four questions were identified via premeeting teleconferences. (1) Should antipsychotic treatment of first-episode schizophrenia be different from that of multiepisode schizophrenia? (2) In which algorithm stages should first-generation antipsychotics (FGAs) be an option? (3) How many antipsychotic trials should precede a clozapine trial? (4) What is the status of augmentation strategies for clozapine? Subgroups reviewed the evidence in each area and presented their findings at the conference. RESULTS: The algorithm was updated to incorporate the following recommendations. (1) Persons with first-episode schizophrenia typically require lower antipsychotic doses and are more sensitive to side effects such as weight gain and extrapyramidal symptoms (group consensus). Second-generation antipsychotics (SGAs) are preferred for treatment of first-episode schizophrenia (majority opinion). (2) FGAs should be included in algorithm stages after first episode that include SGAs other than clozapine as options (group consensus). (3) The recommended number of trials of other antipsychotics that should precede a clozapine trial is 2, but earlier use of clozapine should be considered in the presence of persistent problems such as suicidality, comorbid violence, and substance abuse (group consensus). (4) Augmentation is reasonable for persons with inadequate response to clozapine, but published results on augmenting agents have not identified replicable positive results (group consensus). CONCLUSIONS: These recommendations are meant to provide a framework for clinical decision making, not to replace clinical judgment. As with any algorithm, treatment practices will evolve beyond the recommendations of this consensus conference as new evidence and additional medications become available.
Asunto(s)
Algoritmos , Antipsicóticos/uso terapéutico , Clozapina/uso terapéutico , Quimioterapia/normas , Quimioterapia/tendencias , Servicios de Salud Mental/tendencias , Esquizofrenia/tratamiento farmacológico , Antipsicóticos/efectos adversos , Enfermedades de los Ganglios Basales/inducido químicamente , Enfermedades de los Ganglios Basales/epidemiología , Clozapina/efectos adversos , Humanos , Esquizofrenia/diagnóstico , Esquizofrenia/epidemiología , Trastornos Relacionados con Sustancias/epidemiología , Intento de Suicidio/psicología , Intento de Suicidio/estadística & datos numéricos , Texas , Violencia/psicología , Aumento de Peso/efectos de los fármacosRESUMEN
BACKGROUND: The Texas Medication Algorithm Project (TMAP) has been a public-academic collaboration in which guidelines for medication treatment of schizophrenia, bipolar disorder, and major depressive disorder were used in selected public outpatient clinics in Texas. Subsequently, these algorithms were implemented throughout Texas and are being used in other states. Guidelines require updating when significant new evidence emerges; the antipsychotic algorithm for schizophrenia was last updated in 1999. This article reports the recommendations developed in 2002 and 2003 by a group of experts, clinicians, and administrators. METHOD: A conference in January 2002 began the update process. Before the conference, experts in the pharmacologic treatment of schizophrenia, clinicians, and administrators reviewed literature topics and prepared presentations. Topics included ziprasidone's inclusion in the algorithm, the number of antipsychotics tried before clozapine, and the role of first generation antipsychotics. Data were rated according to Agency for Healthcare Research and Quality criteria. After discussing the presentations, conference attendees arrived at consensus recommendations. Consideration of aripiprazole's inclusion was subsequently handled by electronic communications. RESULTS: The antipsychotic algorithm for schizophrenia was updated to include ziprasidone and aripiprazole among the first-line agents. Relative to the prior algorithm, the number of stages before clozapine was reduced. First generation antipsychotics were included but not as first-line choices. For patients refusing or not responding to clozapine and clozapine augmentation, preference was given to trying monotherapy with another antipsychotic before resorting to antipsychotic combinations. CONCLUSION: Consensus on algorithm revisions was achieved, but only further well-controlled research will answer many key questions about sequence and type of medication treatments of schizophrenia.
Asunto(s)
Algoritmos , Antipsicóticos/uso terapéutico , Esquizofrenia/tratamiento farmacológico , Atención Ambulatoria/normas , Instituciones de Atención Ambulatoria/normas , Antipsicóticos/normas , Aripiprazol , Clozapina/uso terapéutico , Árboles de Decisión , Esquema de Medicación , Quimioterapia Combinada , Humanos , Piperazinas/uso terapéutico , Guías de Práctica Clínica como Asunto , Quinolonas/uso terapéutico , Esquizofrenia/diagnóstico , Psicología del Esquizofrénico , Texas , Tiazoles/uso terapéutico , Resultado del TratamientoRESUMEN
This study compares ratings obtained with an itemized clinician-rated symptom severity measure--the 24-item Brief Psychiatric Rating Scale (BPRS24)--with a Physician Global Rating Scale (PhGRS) and a Patient Global Rating Scale (PtGRS) in assessing treatment outcomes in patients with schizophrenia (SCZ). A total of 91 patients (31 inpatients and 60 outpatients) with SCZ were enrolled in a feasibility study of the use of medication algorithms in the treatment of SCZ. Clinicians completed the BPRS24 and the PhGRS; patients completed the PtGRS at each visit. The analyses reported here were conducted using the original BPRS18 and four items from the BPRS18 that rate the positive symptoms of psychosis (the Positive Symptom Rating Scale or PSRS), comparing anchored with global rating scales and with one another. The PtGRS had the lowest effect size (0.8) and was negatively correlated with the other ratings in inpatients. The PhGRS was significantly correlated (0.46) with the BPRS18, but the same person completed both ratings. The effect size of the PhGRS (0.6) was generally lower than with the BPRS18 (1.4) in differentiating responders from non-responders. On average, the PSRS had a slightly lower effect size than the longer itemized BPRS18, but the results support its use as a quantitative rating in circumstances where it is not feasible to routinely use a lengthier scale.
Asunto(s)
Escalas de Valoración Psiquiátrica Breve/normas , Escalas de Valoración Psiquiátrica/normas , Esquizofrenia/diagnóstico , Psicología del Esquizofrénico , Adolescente , Adulto , Análisis de Varianza , Escalas de Valoración Psiquiátrica Breve/estadística & datos numéricos , Estudios de Factibilidad , Femenino , Humanos , Pacientes Internos/psicología , Pacientes Internos/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Pacientes Ambulatorios/psicología , Pacientes Ambulatorios/estadística & datos numéricos , Determinación de la Personalidad/estadística & datos numéricos , Inventario de Personalidad/estadística & datos numéricos , Proyectos Piloto , Escalas de Valoración Psiquiátrica/estadística & datos numéricos , Reproducibilidad de los Resultados , Índice de Severidad de la Enfermedad , Factores de TiempoRESUMEN
The authors evaluated the efficacy of fluoxetine hydrochloride (Prozac; Eli Lilly and Company, Indianapolis, IN) as an adjunct to behavioral treatment for smoking cessation. Sixteen sites randomized 989 smokers to 3 dose conditions: 10 weeks of placebo, 30 mg, or 60 mg fluoxetine per day. Smokers received 9 sessions of individualized cognitive-behavioral therapy, and biologically verified 7-day self-reported abstinence follow-ups were conducted at 1, 3, and 6 months posttreatment. Analyses assuming missing data counted as smoking observed no treatment difference in outcomes. Pattern-mixture analysis that estimates treatment effects in the presence of missing data observed enhanced quit rates associated with both the 60-mg and 30-mg doses. Results support a modest, short-term effect of fluoxetine on smoking cessation and consideration of alternative models for handling missing data.