title: The Texas Medication Algorithm Project antipsychotic algorithm for schizophrenia: 2003 update.
abstract: 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.
authors.affiliation: 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
authors.forename: Alexander  L
authors.initials: A
authors.lastname: Miller
authors.forename: Catherine S
authors.initials: CS
authors.lastname: Hall
authors.forename: Robert W
authors.initials: RW
authors.lastname: Buchanan
authors.forename: Peter F
authors.initials: PF
authors.lastname: Buckley
authors.forename: John A
authors.initials: JA
authors.lastname: Chiles
authors.forename: Robert R
authors.initials: RR
authors.lastname: Conley
authors.forename: M Lynn
authors.initials: ML
authors.lastname: Crismon
authors.forename: Larry
authors.initials: L
authors.lastname: Ereshefsky
authors.forename: Susan M
authors.initials: SM
authors.lastname: Essock
authors.forename: Molly
authors.initials: M
authors.lastname: Finnerty
authors.forename: Stephen R
authors.initials: SR
authors.lastname: Marder
authors.forename: Del D
authors.initials: DD
authors.lastname: Miller
authors.forename: Joseph P
authors.initials: JP
authors.lastname: McEvoy
authors.forename: A John
authors.initials: AJ
authors.lastname: Rush
authors.forename: Sy A
authors.initials: SA
authors.lastname: Saeed
authors.forename: Nina R
authors.initials: NR
authors.lastname: Schooler
authors.forename: Steven P
authors.initials: SP
authors.lastname: Shon
authors.forename: Scott
authors.initials: S
authors.lastname: Stroup
authors.forename: Bernardo
authors.initials: B
authors.lastname: Tarin-Godoy
mesh_terms: 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
chemical_list: D014150:Antipsychotic Agents; D010879:Piperazines; D015363:Quinolones; D013844:Thiazoles; C092292:ziprasidone; D000068180:Aripiprazole; D003024:Clozapine