| 1. Pharmacological intervention |
| General aspects |
A |
Whenever possible, antipsychotic medication should be prescribed in a non-coercitive manner in combination with psychosocial interventions that include adherence-promoting strategies.1 |
| A |
Antipsychotic medications are indicated in nearly all patients who experience an acute relapse; the selection of medication should be guided by the individual characteristics of each patient.2 |
| C |
Weight and body mass index should be measured at the beginning of treatment, then every month for six months, and after that every three months. Consultation with a die titian is advisable, as well as encouraging regular physical exercise. It may also be necessary to consider a drug with a smaller risk of weight gain if weight does not change or is significant. Pros and cons should be assessed with the patient, and he/she should be provided with psychosocial support.1 |
| C |
Fasting plasma glycaemia and lipid profiles should be measured at baseline and at regular intervals over its course.1 |
| C |
An optimum initial assessment should include magnetic resonance imaging, neurocognitive assessment, neurological exam of neurological and motor disorders, an electrocardiogram, height and weight measurement (body mass index), illegal substance detection tests, lipid profiles and fasting plasma glycaemia (and/or HbA1c).1 |
| Prescription of antipsychotics and side effects |
| A |
Pharmacological treatments should be prescribed with extreme caution in patients who have not undergone prior treatment, under the basic principle of producing the least harm possible, while obtaining the maximum benefit. This means a gradual introduction, after careful explanation, of low doses of antipsychotic medication together with antimania or antidepressant drugs when these syndromes are present.1 |
| A |
In patients who initiate treatment for the first time, second-generation antipsychotic medication is recommended given that it is justified due to its better tolerance and lower risk of tardive dyskinesia.1 |
| A |
The use of oral second-generation medication such as risperidone, olanzapine, quetiapine, amisulpride and aripiprazole is recommended as the first and second line of treatment in the first episode of psychosis. Initial doses should be low and then be gradually increased little by little at spaced out intervals only if response is low or incomplete. Secondary discomfort, insomnia and restlessness should be initially treated with benzodiazepines. Other symptoms such as mania and severe depression require specific treatment with mood stabilisers and antidepressants.1 |
| C |
These doses probably will not have an early effect (during the first days) on discomfort, insomnia and behavioural disorders secondary to psychosis. Hence, a safe, supportive context, and regular and sufficient dose of benzodiazepines will provisionally represent essential components in the management of specialised nursing care.1 |
| C |
If the risk-benefit relationship changes in certain patients due to, for example, weight gain, impaired glucose tolerance or sexual side effects associated with the development of second generation agents, an alternative first or second generation antipsychotic drug should be reconsidered.1 |
| C |
In emergency situations it is recommended to avoid the first choice use of drugs that tend to undermine the future adherence to treatment due to the production of undesirable side effects that generate an aversive subjective effect. First generation drugs should be used only as a last resort in these circumstances, particularly haloperidol, given that they produce more rigidity than sedation.1 |
| C |
If in the first episode of non-affective psychosis there are side effects, such as weight gain or metabolic syndrome, the use of a conventional antipsychotic is recommended. If response is insufficient, other causes should be assessed. If there are no side effects, doses should be increased. If adherence is poor, analyse the reasons, optimize the doses and provide treatment compliance therapy.1
|
| Technical aspects of prescription |
| A |
Maintenance of pharmacotherapy is recommended for the prevention of relapse in stable and stabilisation phases, with doses that are always within the recommended treatment range for first and second generation antipsychotics.2 |
| B |
Antipsychotic medication for the treatment of a first episode of psychosis should be maintained for at least two years after the first recovery from symptoms.2
|
| B |
In a first episode of psychosis, dosage should be initiated in the lower half of the treatment range; second generation antipsychotics are indicated due to the lower short and long term risk of extrapyramidal side effects.2
|
| B |
The use of clozapine is recommended in cases of persistent aggressiveness.2
|
| B |
The administration of multiple antipsychotic drugs, such as the combination of first and second generation drugs, should not be used except during transition phases of switching from one medication to another.1
|
| C |
Antipsychotic drugs, whether second or first generation, should not be prescribed simultaneously, except for brief periods of time during a transition phase.3
|
| C |
The combination of two antipsychotics is not recommended, given that it could increase the risk of side effects and pharmacokinetic interactions.3
|
| C |
The recommendation to combine an antipsychotic drug, a mood stabiliser and a benzodiazepine or antidepressant could be totally justified by the characteristics of comorbid symptoms, which are extremely common in psychotic disorders.1
|
| C |
If parenteral treatment is deemed necessary, intramuscular administration is preferable to intravenous, from the point of view of safety. Intravenous administration should only be used in specific circumstances.3
|
| C |
Vital signs should be monitored after parenteral administration of treatment. Blood pressure, pulse rate, body temperature and respiratory rate should be recorded at regular intervals, established by the multidisciplinary team, until the patient is active again. If he/she is asleep or seems to be so, more intensive monitoring is required.3
|
| C |
Depot drugs should be reserved for two groups. Firstly, for those who clearly and voluntarily choose this administration route. Second generation injectable drugs are preferable due to their better tolerability and lower risk of tardive dyskinesia. Secondly, for those who, despite a series of comprehensive psychosocial interventions aimed at promoting adaptation and adherence, repeatedly fail to adhere to the necessary medication and present frequent relapses. This is even more pressing when the consequences of relapses are severe and entail substantial risk both for the patient and for others.1 |
| Resistance to antipsychotic treatment |
| A |
Patients who are taking first generation antipsychotic drugs and who still present persistent positive or negative symptoms, or who experience uncomfortable side effects, should switch to oral second generation antipsychotic medication under close surveillance of a specialist.1
|
| A |
If the risk of suicide is high or persistent despite treatment for depression, if antidepressant treatment is ineffective, or if depression is not severe, the immediate use of clozapine should be considered.1
|
| A |
Second generation medication is recommended for patients who relapse in spite of good adherence to first generation antipsychotic medication, although other reversible causes of relapse should be taken into account.1
|
| A |
If the patient is resistant to treatment, clozapine should be introduced with safety guarantees on the very first administration.1
|
| A |
When there is no response to treatment with adequate administration of two different antipsychotics, the use of clozapine is recommended.2
|
| B |
Depot antipsychotic drugs should be considered for those patients who present poor adherence to medication.2
|
| C |
If schizophrenia symptoms do not respond to first generation antipsychotics, the use of a second generation antipsychotic should be considered before diagnosing treatment-resistant schizophrenia or introducing clozapine. In these cases, the introduction of olanzapine or risperidone can be assessed. It is recommended to inform the patients.3
|
| C |
The addition of a second antipsychotic to clozapine could be considered in people resistant to treatment in whom clozapine alone has not been proven to be sufficiently effective.3
|
| 2.1. Cognitive-Behavioural Therapy |
| A |
Cognitive-behavioural therapy (CBT) is recommended for the treatment of psychotic symptoms that are persistent despite receiving adequate pharmacological treatment.3 |
| A |
CBT should be indicated for the treatment of positive symptoms of schizophrenia, especially hallucinations.7 |
| A |
CBT is recommended as a treatment option to aid in the development of insight and to increase adherence to treatment.7 |
| A |
CBT is recommended to prevent the evolution to psychosis in early intervention.8 |
| A |
CBT is recommended as a treatment option to prevent the prescription of drugs and reduce symptomatology in the management of incipient psychosis.8 |
| A |
CBT, together with standard care, is recommended in the acute phase to accelerate recovery and hospital discharge.1 |
| B |
CBT should be considered for the treatment of stress, anxiety and depression in patients with schizophrenia and consequently the techniques employed should be adapted to other populations accordingly.2 |
| 2.5. Family intervention |
| A |
Family Intervention (FI) programs are recommended to reduce the burden on the family, improve social functioning of the patient and reduce economic cost.11,12 |
| A |
The application of FI therapy is recommended in patients who are moderately or severely disabled and, especially, in those with long evolution of the disorder. In patients with recent onset of the disease, each situation will have to be individually assessed.11,12 |
| A |
FI should be offered to families who live together or who are in contact with patients with schizophrenia, especially those who have relapsed or present relapse risk, and also in cases of persistent symptomatology.3 |
| A |
Psychoeducational FI, based on the management of expressed emotion, is recommended to avoid relapses and improve the prognosis of the disease (its effects are maintained at 24 months)..11-16 |
| A |
Programs should be applied in groups comprised of family members of similar patients, taking expressed emotion into account and should include the patient to the greatest possible extent. These programs should be added to standard treatment and should never last under six months in order for them to be effective.11,12 |
| A |
Patients should be included, whenever possible, in FI sessions given that it significantly reduces relapses.3 |
| A |
Prolonged FI (over six months) is recommended to reduce relapses.3 |
| A |
Patients and their families usually prefer single family interventions rather than multifamily group interventions.3 |
| A |
Programs should always include information for the families regarding the disease along with different strategies, such as stress coping strategies or problem-solving training.17,18 |
| B |
Referral to patient and carer social networks is recommended.1 |
| B |
FI programs should last more than nine months and include characteristics of commitment to attend the program, support and development of skills and should not simply provide information or shared knowledge.2 |
| C |
It is recommended to transmit information gradually depending on the needs and uncertainties of the patient and his/her family and the phase of the disorder the patient is in.3 |
| 2.9. Occupational insertion support |
| A |
It is recommended to encourage people with schizophrenia to find employment. Mental health specialists should actively facilitate it and specific programs that incorporate this intervention should be widely established.1 |
| A |
Supported employment programs are recommended for the occupational insertion of patients with schizophrenia, given that better outcomes are obtained when compared to other occupational rehabilitation interventions.22,23 |
| A |
It is recommended to provide occupational support to moderately or mildly disabled patients and who are in the stable or maintenance phase.24,25 |
| C |
Mental health services, in collaboration with social and health care staff and other relevant local groups, should facilitate access to employment opportunities, including an array of support modalities adapted to the different needs and abilities of people with schizophrenia.3 |
