Long term treatment of schizophrenia: WFSBP Recommendations:2012-2013.

13.02.2013 ( Part 2)

Recommendations:

Which medication?: FGAs and SGAs do not show general differences in reducing symptoms with long-term treatment. Some evidence support superiority of certain SGAs with regard to treatment discontinuation and relapse prevention.The reduced risk of inducing motor side effects might favour certain SGAs. Certain SGAs may have some advantages in reducing negative symptoms as well.Tardive dyskinesia and metabolic side effects seem to have the greatest impact on the patient’s wellbeing and health – these side effects need to be monitored continuously and treated as soon as possible.

Maintenance treatment should be carried forward with the antipsychotic  which led to the best response and which had the best individual side effect profile during the acute episode.  Selection procedure must be undertaken individually, respecting the patient’s experience and side effect profile.

How long?: A continuous antipsychotic for at least one year for first-episode patients is recommended.For multiple-episode patients, maintenance treatment duration of at least 2–5 years (in severe cases life-long treatment) should be taken into consideration. Indefinite continuation of antipsychotic medications is recommended for patients with a history of serious suicide attempts or violent, aggressive behaviour and very frequent relapses.

Role of Depot: There is good evidence to support the use of FGA depot antipsychotics for relapse prevention , but  there is no clear difference in efficacy between oral and depot formulations.There is good evidence to support the use of long-acting injectable risperidone, paliperidone and olanzapine. There is some evidence to support superiority of the risperidone depot compared to the oral preparation.There is no evidence to support  superiority of the depot paliperidone compared to oral paliperidone .Three hour observation period is required following olanzapine depot injection (postinjection delirium sedation syndrome).

Comments:

This guideline cover only the biological treatments.Psychosocial interventions are crucial in long-term care. Involving the individual in treatment plans is essential for success.Most of these recommendations appear to be in tune with current practice.

Comment on ECT: There is limited evidence for the general efficacy of ECT in treatment-resistant schizophrenia.In certain cases ECT add-on to antipsychotic treatment may be appropriate. In catatonia ECT is still an important therapeutic alternative.

Summary of the article:

World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia, Part 2:Update 2012 on the long-term treatment of schizophrenia and management of antipsychotic-induced side effects. Hasan A, Falkai P, Wobrock T, Lieberman J, Glenthoj B, Gattaz WF, Thibaut F, Möller HJ; WFSBP Task force on TreatmentGuidelines for Schizophrenia.World J Biol Psychiatry. 2013 Feb;14(1):2-44.