The treatment of schizophrenia: Can we raise the standard of care?
OBJECTIVE
There is evidence that over time health outcomes of people with schizophrenia are deteriorating rather than improving both in terms of mortality rate and levels of morbidity, even in Australia where service resourcing is substantial. Our objective was to examine the evidence of whether poor outcomes reflect decreases in treatment effectiveness and, if so, what are the barriers to improving standards of care. This review will argue that the confidence of clinicians to diagnose schizophrenia early, and provide assertive and long-term care, may be being undermined by a series of controversies in the published literature and discrepancies in clinical practice guidelines.


METHODS
A critical review was conducted of the evidence regarding six issues of high clinical relevance to the treatment of schizophrenia formulated as questions: (1) Is schizophrenia a progressive disease? (2) Does relapse contribute to disease progression and treatment resistance? (3) When should the diagnosis of schizophrenia be made? (4) Should maintenance antipsychotic medication be discontinued in fully remitted first-episode patients? (5) Do antipsychotic medications cause deleterious reductions in cortical grey matter volumes? and (6) Are long-acting injectable antipsychotics more effective in reducing relapse rate compared to oral formulations?


RESULTS
There is reliable evidence for schizophrenia being a progressive disease with emergent treatment resistance in most cases, that relapse contributes to this treatment resistance, that maintenance antipsychotic medication should not be discontinued in remitted first-episode patients, that antipsychotic medication does not appear to cause deleterious grey matter volume changes, that maintenance antipsychotic medication reduces the mortality rate in schizophrenia and that long-acting injectable antipsychotics are more effective in preventing relapse than oral formulations.


CONCLUSIONS
There is an urgent need to re-engineer the early management of schizophrenia and to routinely evaluate this type of innovation within practice-based research networks. A proposal for an assertive treatment algorithm is included.
Discipline of Psychiatry, Royal Brisbane Clinical School, School of Medicine, The University of Queensland, Herston, QLD, Australia s.catts@uq.edu.au.|Brain and Mind Centre, The University of Sydney, Camperdown, NSW, Australia.|Neuroscience Research Australia, Randwick, NSW, Australia.
Stanley Victor
SV
Catts
Brain and Mind Centre, The University of Sydney, Camperdown, NSW, Australia.
Brian Ignatius
BI
O'Toole
D014150:Antipsychotic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D012559:Schizophrenia / Q000188:drug therapy*; D059039:Standard of Care / Q000592:standards*
D014150:Antipsychotic Agents
Schizophrenia; algorithm; medication; outcomes; treatment