New guidelines emphasise the GP’s role in monitoring and reducing the cardiovascular risk of schizophrenic patients
New guidelines put the GP front and centre of managing schizophrenia, but experts worry that without better resourcing, the gold-standard may only be aspirational.
The Royal Australian and NZ College of Psychiatrists’ clinical guidelines for schizophrenia, the first update in more than a decade, emphasise the need for early management of both the schizophrenic symptoms, but also cardiovascular and metabolic problems associated with the illness.
In an accompanying editorial, psychiatrist Professor Patrick McGorry and colleague lament Australia’s “healthcare apartheid” that heaps money and resources onto illnesses such as cancer and neglects serious mental illnesses such schizophrenia.
“Imagine if chemotherapy sessions were capped on such an arbitrary basis [as Better Access],” they wrote.
“Hard-won scientific evidence now shows that if, as with other non-communicable diseases, our mental-health system placed a premium on early diagnosis, provided intensive expert care from the onset of illness, and sustained that care over the duration of the illness, life expectancy and functional outcomes would be greatly improved.”
Professor Jayashri Kulkarni, an author of the new clinical practice guidelines, said she hoped the guidelines would help clarify the latest evidence for GPs, who are saddled with the bulk of continuing care for patients with schizophrenia.
As well as providing specific recommendations on pharmacological options for patients, the new guidelines emphasise the GP role in monitoring and reducing the cardiovascular risk of their schizophrenic patients.
This includes a full physical and neurological examination of patients at their first episode of psychosis, comprising of a full blood count, electrolytes and liver function tests, and tests for fasting glucose, lipids and thyroid function.
The guidelines also recommend testing for hepatitis, and performing a urine drug screen and ECG.
When clinically appropriate, tests for HIV and other STIs, as well as anti-NMDAR, anti-VGKC and anti-GAD antibodies, electroencephalograms and brain MRIs, are advised. Regular metabolic monitoring should be done in these patients, testing most at baseline, then 12 and 24 weeks, then at least annually.
They also recommend checking BMI in weeks four and eight.
Unlike the previous guideline, this update provided a clinical staging approach to guide treatment, not just in the early stages, but also in the middle and established part of the illness, Professor Kulkarni said.
The authors stressed the importance of treatment of the first episode of frank psychosis “as it is a very sensitive part of the illness journey, and one in which getting it right is particularly important for patient and family engagement, and for determining the longitudinal trajectory of the illness”.
Here, the best treatment was the lowest effective dose of an antipsychotic, and a second generation antipsychotic was suggested. The group did not recommend olanzapine for first-line use due to the potential metabolic impact.
“GPs are seen as a linchpin of the treatment team,” the authors wrote in their summary in the MJA.
“As the individual moves further along the stages of illness, it is important to implement a recovery plan that is negotiated with the patient and open to regular review.”
They recommended developing a comprehensive treatment plan that incorporated psychological and psychosocial approaches, addressing issues affecting areas such as work, school and relationships.
Patients with schizophrenia were also at risk of a number of physical comorbidities, and so advising them about exercise and healthy diet was useful in protecting against metabolic problems. Drugs such as aripiprazole, amisulpride, asenapine, lurasidone and ziprasidone were good alternatives if weight gain and other metabolic problems arose.
Smoking, sleep disorders and dental problems were other common comorbidities requiring vigilance and help, if possible.
Sleep problems, in particular, commonly flew under the radar, with clinicians attributing the lethargy and fatigue to the other schizophrenia symptoms, the authors said.
MJA 2017; online 19 June
An earlier version of this article incorrectly stated Professor Kulkarni was a co-author of the Professor McGorry’s editorial.
