Guideline Updates in Schizophrenia

On an episode of the Carlat Psychiatry Podcast, Chris Aiken, MD, Kellie Newsome, PMHNP, and Brian Miller, MD, PhD, MPH, discuss new American Psychiatric Association (APA) schizophrenia treatment guidelines, which recommend clozapine when patients fail to respond to 2 antipsychotics—but only approximately 5% receive clozapine in the United States. Other countries see rates of clozapine prescriptions that are much more in line with where the APA would like them to be.

These aren’t the first guidelines to recommend the “baseball approach” to clozapine, meaning 2 strikes and 1 gets a trial. The APA no longer requires that one of those trials be a first-generation antipsychotic, so one can move to clozapine after 2 failed trials of atypical antipsychotics. In some patients, they now recommend clozapine as first- or second-line therapy, such as in people with schizophrenia who have significant aggression, suicidality, or self-harm.

Another big change in the guidelines is blood levels, which are not used routinely in schizophrenia assessment, but the guidelines suggest checking antipsychotic blood levels to ascertain if the patient is even taking the medication, particularly before he or she moves to clozapine.

Reference: Schizophrenia: Catching Up to New Guidelines. Carlat Publishing. Published February 14, 2022. Accessed July 8, 2022.