CLINICAL HANDBOOK OF SCHIZOPHRENIA

148 II. ASSESSMENT AND DIAGNOSISTABLE 15.2. Evidence-Based and Promising Practices for Treatment of Schizophrenia1. Medications2. Psychosocial approachesa. Cognitive-behavioral therapy (CBT)b. Compliance therapy/motivational interviewing/shared decision makingc. Cognitive remediationd. Social skills traininge. Assertive community treatment (ACT)f. Cognitive adaptation training (CAT)g. Supported employmenth. Family therapiesi Integrated dual-diagnosis treatmentj. Supported housingness of the potential value of the practice for the patient and, cumulatively, is a basis forestimating the need for the practice, if resources can be channeled into providing it.MEDICATION TREATMENT PLANNINGThere is general agreement that antipsychotics are mainstays in the treatment ofchronic schizophrenia, and that psychotic symptoms are their primary target. Often,however, treatment plans do not specify how symptoms will be measured, or whichside effects will be assessed and how often. In addition, explication of the rationale forchoosing a particular antipsychotic and discussion of possible alternatives in the eventof poor responses occur infrequently. The value of including these items is that theyhelp lay out a road map for treatment to guide other prescribers who see the patient inother settings, or when the primary prescriber is absent, or if the primary prescriberceases seeing the patient for whatever reason. It is a common and frustrating experienceto see a patient on a complex medication regimen for the first time and not beable to discern why the regimen is being used and whether it is producing better resultsthan prior, simpler treatment programs.Many persons with schizophrenia have coexisting conditions and symptoms thatwarrant treatment with other medications, such as antidepressants, antianxiety agents,and sedative–hypnotics. Use of these medications for appropriate indications is completelywarranted and desirable. It is, however, a common observation that, once started,these adjunctive medications are continued indefinitely. A key part of medication treatmentplanning is ongoing review of the entire medication regimen, with the goal ofdiscontinuing medications that are no longer needed. Simplification of the medicationregimen enhances adherence, decreases the likelihood of undesirable side effects anddrug–drug interactions, and reduces costs.Many practitioners and organizations choose to follow a recent medication guidelineor algorithm for schizophrenia. This approach takes advantage of the expert knowledgeand opinions that have gone into construction of the algorithm or guideline and helps definethe sequence of medications to be used in the event of inadequate response. Moreover,when followed by a clinic or group of providers, it brings desirable consistency tomedication management across time and patients. Some recent guidelines and algorithmsare listed in Table 15.4, with comments about their content and utility.Implementation of a guideline or algorithm requires that there be enough specificityin the recommendations that a prescriber can apply them to specific patient care circum-