The Texas Medication Algorithm Project antipsychotic algorithm for schizophrenia: 2003 update.
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.


METHODS
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.


CONCLUSIONS
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.
Miller
Alexander  L
A
Department of Psychiatry, The University of Texas Health Science Center at San Antonio, MC 7792, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA. millera@uthscsa.edu
Hall
Catherine S
CS
Buchanan
Robert W
RW
Buckley
Peter F
PF
Chiles
John A
JA
Conley
Robert R
RR
Crismon
M Lynn
ML
Ereshefsky
Larry
L
Essock
Susan M
SM
Finnerty
Molly
M
Marder
Stephen R
SR
Miller
Del D
DD
McEvoy
Joseph P
JP
Rush
A John
AJ
Saeed
Sy A
SA
Schooler
Nina R
NR
Shon
Steven P
SP
Stroup
Scott
S
Tarin-Godoy
Bernardo
B
D000465:Algorithms; D000553:Ambulatory Care / Q000592:standards; D000554:Ambulatory Care Facilities / Q000592:standards; D014150:Antipsychotic Agents / Q000592:standards / Q000627:therapeutic use*; D000068180:Aripiprazole; D003024:Clozapine / Q000627:therapeutic use; D003663:Decision Trees; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D006801:Humans; D010879:Piperazines / Q000627:therapeutic use; D017410:Practice Guidelines as Topic; D015363:Quinolones / Q000627:therapeutic use; D012559:Schizophrenia / Q000175:diagnosis / Q000188:drug therapy*; D012565:Schizophrenic Psychology; D013781:Texas; D013844:Thiazoles / Q000627:therapeutic use; D016896:Treatment Outcome
D014150:Antipsychotic Agents; D010879:Piperazines; D015363:Quinolones; D013844:Thiazoles; C092292:ziprasidone; D000068180:Aripiprazole; D003024:Clozapine