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Brief Summary


Practice guideline for the treatment of patients with schizophrenia. Second edition.


  • American Psychiatric Association. Practice guideline for the treatment of patients with schizophrenia. 2nd ed. Arlington (VA): American Psychiatric Association; 2004 Feb. 114 p. [1391 references]


This is the current release of the guideline.

This guideline updates a previous version:

American Psychiatric Association (APA). Practice guideline for the treatment of patients with schizophrenia. Washington (DC): American Psychiatric Press, Inc; 1997. 146 p.

Practice guideline for the treatment of patients with schizophrenia. American Psychiatric Association (APA). Am J Psychiatry 1997 Apr;154(4 Suppl):1-63.



Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released.

  • June 17, 2008, Antipsychotics (conventional and atypical]): The U.S. Food and Drug Administration (FDA) notified healthcare professionals that both conventional and atypical antipsychotics are associated with an increased risk of mortality in elderly patients treated for dementia-related psychosis. The prescribing information for all antipsychotic drugs will now include information about the increased risk of death in the BOXED WARNING and WARNING sections.
  • December 12, 2007, Carbamazepine: The U.S. Food and Drug Administration (FDA) has provided recommendations for screening that should be performed on specific patient populations before starting treatment with carbamazepine.
  • September 17, 2007, Haloperidol (Haldol): Johnson and Johnson and the U.S. Food and Drug Administration (FDA) informed healthcare professionals that the WARNINGS section of the prescribing information for haloperidol has been revised to include a new Cardiovascular subsection.



 Go to the Complete Summary



Each recommendation is coded according to the degree of clinical confidence with which the recommendations are made. Definitions of the recommendation coding system are provided below.

  1. Coding System

    Each recommendation is identified as falling into one of three categories of endorsement, indicated by a bracketed Roman numeral following the statement. The three categories represent varying levels of clinical confidence regarding the recommendation:

    [I] Recommended with substantial clinical confidence

    [II] Recommended with moderate clinical confidence

    [III] May be recommended on the basis of individual circumstances

  2. Formulation and Implementation of a Treatment Plan

    Because schizophrenia is a chronic illness that influences virtually all aspects of life of affected persons, treatment planning has three goals: 1) reduce or eliminate symptoms, 2) maximize quality of life and adaptive functioning, and 3) promote and maintain recovery from the debilitating effects of illness to the maximum extent possible. Accurate diagnosis has enormous implications for short- and long-term treatment planning, and it is essential to note that diagnosis is a process rather than a one-time event. As new information becomes available about the patient and his or her symptoms, the patient’s diagnosis should be reevaluated, and, if necessary, the treatment plan changed.

    Once a diagnosis has been established, it is critical to identify the targets of each treatment, to have outcome measures that gauge the effect of treatment, and to have realistic expectations about the degrees of improvement that constitute successful treatment [I]. Targets of treatment, and hence of assessment, may include positive and negative symptoms, depression, suicidal ideation and behaviors, substance use disorders, medical comorbidities, posttraumatic stress disorder (PTSD), and a range of potential community adjustment problems, including homelessness, social isolation, unemployment, victimization, and involvement in the criminal justice system [I].

    After the initial assessment of the patient’s diagnosis and clinical and psychosocial circumstances, a treatment plan must be formulated and implemented. This formulation involves the selection of the treatment modalities, the specific type(s) of treatment, and the treatment setting. Periodic reevaluation of the diagnosis and the treatment plan is essential to good clinical practice and should be iterative and evolve over the course of the patient’s association with the clinician [I].

  3. Establishing a Therapeutic Alliance

    A supportive therapeutic alliance allows the psychiatrist to gain essential information about the patient and allows the patient to develop trust in the psychiatrist and a desire to cooperate with treatment. Identifying the patient’s goals and aspirations and relating these to treatment outcomes fosters the therapeutic relationship as well as treatment adherence [II]. The clinician may also identify practical barriers to the patient’s ability to participate in treatment, such as cognitive impairments or disorganization and inadequate social resources. Engagement of the family and other significant support persons, with the patient’s permission, is recommended to further strengthen the therapeutic effort [I]. The social circumstances of the patient can have profound effects on adherence and response to treatment. Living situation, family involvement, sources and amount of income, legal status, and relationships with significant others (including children) are all areas that may be periodically explored by mental health care clinicians [II]. The psychiatrist can work with team members, the patient, and the family to ensure that such services are coordinated and that referrals for additional services are made when appropriate. The family’s needs can be addressed and an alliance with family members can be facilitated by providing families with information about community resources and about patient and family organizations such as the National Alliance for the Mentally Ill (NAMI) [II].

    Many patients with schizophrenia require, and should receive, a variety of treatments, often from multiple clinicians. It is therefore incumbent on clinicians to coordinate their work and prioritize their efforts. Because an accurate history of past and current treatments and responses to them is a key ingredient to treatment planning, excellent documentation is paramount [I]. Especially critical, for example, is information about prior treatment efforts and clinical response.

  4. Acute Phase Treatment

    The goals of treatment during the acute phase of treatment, defined by an acute psychotic episode, are to prevent harm, control disturbed behavior, reduce the severity of psychosis and associated symptoms (e.g., agitation, aggression, negative symptoms, affective symptoms), determine and address the factors that led to the occurrence of the acute episode, effect a rapid return to the best level of functioning, develop an alliance with the patient and family, formulate short- and long-term treatment plans, and connect the patient with appropriate aftercare in the community. Efforts to engage and collaborate with family members and other natural caregivers are often successful during the crisis of an acute psychotic episode, whether it is the first episode or a relapse, and are strongly recommended [I]. Family members are often under significant stress during this time. Also, family members and other caregivers are often needed to provide support to the patient while he or she is recovering from an acute episode.

    It is recommended that every patient have as thorough an initial evaluation as his or her clinical status allows, including complete psychiatric and general medical histories and physical and mental status examinations [I]. Interviews of family members or other persons knowledgeable about the patient may be conducted routinely, unless the patient refuses to grant permission, especially since many patients are unable to provide a reliable history at the first interview [I]. The most common contributors to symptom relapse are antipsychotic medication nonadherence, substance use, and stressful life events, although relapses are not uncommon as a result of the natural course of the illness despite continuing treatment. If nonadherence is suspected, it is recommended that the reasons for it be evaluated and considered in the treatment plan. General medical health as well as medical conditions that could contribute to symptom exacerbation can be evaluated by medical history, physical and neurological examination, and appropriate laboratory, electrophysiological, and radiological assessments [I]. Measurement of body weight and vital signs (heart rate, blood pressure, temperature) is also recommended [II]. Other laboratory tests to be considered to evaluate health status include a complete blood complete (CBC); measurements of blood electrolytes, glucose, cholesterol, and triglycerides; tests of liver, renal, and thyroid function; a syphilis test; and when indicated and permissible, determination of human immunodeficiency virus (HIV) status and a test for hepatitis C [II]. Routine evaluation of substance use with a toxicology screen is also recommended as part of the medical evaluation [I]. A pregnancy test should be strongly considered for women with childbearing potential [II]. In patients for whom the clinical picture is unclear or where there are abnormal findings from a routine examination, more detailed studies (e.g., screening for heavy metal toxins, electroencephalogram [EEG], magnetic resonance imaging [MRI] scan, or computed tomography [CT] scan) may be indicated [II].

    It is important to pay special attention to the presence of suicidal potential and the presence of command hallucinations and take precautions whenever there is any question about a patient’s suicidal intent, since prior suicide attempts, current depressed mood, and suicidal ideation can be predictive of a subsequent suicide attempt in schizophrenia [I]. Similar evaluations are recommended in considering the likelihood of dangerous or aggressive behavior and whether the person will harm someone else or engage in other forms of violence [I].

    It is recommended that pharmacological treatment be initiated promptly, provided it will not interfere with diagnostic assessment, because acute psychotic exacerbations are associated with emotional distress, disruption to the patient’s life, and a substantial risk of dangerous behaviors to self, others, or property [I]. Before the patient begins treatment with antipsychotic medication, it is suggested that the treating physician, as is feasible, discuss the potential risks and benefits of the medication with the patient [I]. The selection of an antipsychotic medication is frequently guided by the patient’s previous experience with antipsychotics, including the degree of symptom response, past experience of side effects, and preferred route of medication administration. In choosing among these medications, the psychiatrist may consider the patient’s past responses to treatment, the medication’s side effect profile (including subjective responses, such as a dysphoric response to a medication), the patient’s preferences for a particular medication based on past experience, the intended route of administration, the presence of comorbid medical conditions, and potential interactions with other prescribed medications [I]. Finally, while most patients prefer oral medication, patients with recurrent relapses related to nonadherence are candidates for a long-acting injectable antipsychotic medication, as are patients who prefer this mode of administration [II].

    The recommended dose is that which is both effective and not likely to cause side effects that are subjectively difficult to tolerate, since the experience of unpleasant side effects may affect long-term adherence [I]. The dose may be titrated as quickly as tolerated to the target therapeutic dose of the antipsychotic medication, and unless there is evidence that the patient is having uncomfortable side effects, monitoring of the patient’s clinical status for 2–4 weeks is warranted to evaluate the patient’s response to the treatment [II]. During these weeks it is often important for physicians to be patient and avoid the temptation to prematurely escalate the dose for patients who are responding slowly [I]. If the patient is not improving, it may be helpful to establish whether the lack of response can be explained by medication nonadherence, rapid medication metabolism, or poor absorption [II].

    Adjunctive medications are also commonly prescribed for comorbid conditions in the acute phase. Benzodiazepines may be used to treat catatonia as well as to manage both anxiety and agitation until the antipsychotic has had time to be therapeutically effective [II]. Antidepressants can be considered for treating comorbid major depression or obsessive-compulsive disorder, although vigilance to protect against the risk of exacerbation of psychosis with some antidepressants is important [II]. Mood stabilizers and beta-blockers may be considered for reducing the severity of recurrent hostility and aggression [II]. Careful attention must be paid to potential drug-drug interactions, especially those related to metabolism by cytochrome P450 enzymes [I].

    Psychosocial interventions in the acute phase are aimed at reducing overstimulating or stressful relationships, environments, or life events and at promoting relaxation or reduced arousal through simple, clear, coherent communications and expectations; a structured and predictable environment; low performance requirements; and tolerant, nondemanding, supportive relationships with the psychiatrist and other members of the treatment team. Providing information to the patient and the family on the nature and management of the illness that is appropriate to the patient’s capacity to assimilate information is recommended [II]. Patients can be encouraged to collaborate with the psychiatrist in selecting and adjusting the medication and other treatments provided [II].

    The acute phase is also the best time for the psychiatrist to initiate a relationship with family members, who tend to be particularly concerned about the patient’s disorder, disability, and prognosis during the acute phase and during hospitalization [I]. Educational meetings, "survival workshops" that teach the family how to cope with schizophrenia, and referrals to local chapters of patient and family organizations such as NAMI may be helpful and are recommended [III]. Family members may be under considerable stress, particularly if the patient has been exhibiting dangerous or unstable behavior.

  1. Stabilization Phase

    During the stabilization phase, the goals of treatment are to reduce stress on the patient and provide support to minimize the likelihood of relapse, enhance the patient’s adaptation to life in the community, facilitate continued reduction in symptoms and consolidation of remission, and promote the process of recovery. If the patient has improved with a particular medication regimen, continuation of that regimen and monitoring are recommended for at least 6 months [I]. Premature lowering of dose or discontinuation of medication during this phase may lead to a recurrence of symptoms and possible relapse. It is also critical to assess continuing side effects that may have been present in the acute phase and to adjust pharmacotherapy accordingly to minimize adverse side effects that may otherwise lead to medication nonadherence and relapse [I].

    Psychosocial interventions remain supportive but may be less structured and directive than in the acute phase [III]. Education about the course and outcome of the illness and about factors that influence the course and outcome, including treatment adherence, can begin in this phase for patients and continue for family members [II].

    It is important that there be no gaps in service delivery, because patients are particularly vulnerable to relapse after an acute episode and need support in resuming their normal life and activities in the community [I]. For hospitalized patients, it is frequently beneficial to arrange an appointment with an outpatient psychiatrist and, for patients who will reside in a community residence, to arrange a visit before discharge [II]. Adjustment to life in the community for patients can be facilitated through realistic goal setting without undue pressure to perform at high levels vocationally and socially, since unduly ambitious expectations can be stressful and can increase the risk of relapse [I]. While it is critical not to place premature demands on the patient regarding engagement in community-based activities and rehabilitation services, it is equally critical to maintain a level of momentum aimed at improving community functioning in order to instill a sense of hope and progress for the patient and family [I].

  2. Stable Phase

    The goals of treatment during the stable phase are to ensure that symptom remission or control is sustained, that the patient is maintaining or improving his or her level of functioning and quality of life, that increases in symptoms or relapses are effectively treated, and that monitoring for adverse treatment effects continues. Regular monitoring for adverse effects is recommended [I]. If the patient agrees, it is helpful to maintain strong ties with persons who interact with the patient frequently and would therefore be most likely to notice any resurgence of symptoms and the occurrence of life stresses and events that may increase the risk of relapse or impede continuing functional recovery [II]. For most persons with schizophrenia in the stable phase, psychosocial interventions are recommended as a useful adjunctive treatment to pharmacological treatment and may improve outcomes [I].

    Antipsychotic medications substantially reduce the risk of relapse in the stable phase of illness and are strongly recommended [I]. Deciding on the dose of an antipsychotic medication during the stable phase is complicated by the fact that there is no reliable strategy available to identify the minimum effective dose to prevent relapse. For most patients treated with first-generation antipsychotics, a dose is recommended that is around the "extrapyramidal symptom (EPS) threshold" (i.e., the dose that will induce extrapyramidal side effects with minimal rigidity detectable on physical examination), since studies indicate that higher doses are usually not more efficacious and increase the risk of subjectively intolerable side effects [II]. Lower doses of first-generation antipsychotic medications may be associated with improved adherence and better subjective state and perhaps ultimately better functioning. Second-generation antipsychotics can generally be administered at doses that are therapeutic yet well below the "extrapyramidal symptom threshold." The advantages of decreasing antipsychotic doses to minimize side effects can be weighed against the disadvantage of a somewhat greater risk of relapse and more frequent exacerbations of schizophrenic symptoms. In general, it is more important to prevent relapse and maintain the stability of the patient [III].

    The available antipsychotic medications are associated with differential risk of a variety of side effects, including neurological, metabolic, sexual, endocrine, sedative, and cardiovascular side effects. Monitoring of side effects based on the side effect profile of the prescribed antipsychotic is warranted. During the stable phase of treatment, it is important to routinely monitor all patients treated with antipsychotics for extrapyramidal side effects and the development of tardive dyskinesia [I]. Because of the risk of weight gain associated with many antipsychotics, regular measurement of weight and body mass index (BMI) is recommended [I]. Routine monitoring for obesity-related health problems (e.g., high blood pressure, lipid abnormalities, and clinical symptoms of diabetes) and consideration of appropriate interventions are recommended particularly for patients with body mass index in the overweight and obese ranges [II]. Clinicians may consider regular monitoring of fasting glucose or hemoglobin A1c levels to detect emerging diabetes, since patients often have multiple risk factors for diabetes, especially patients with obesity [I].

    Antipsychotic treatment often results in substantial improvement or even remission of positive symptoms. However, most patients remain functionally impaired because of negative symptoms, cognitive deficits, and limited social function. It is important to evaluate whether residual negative symptoms are in fact secondary to a parkinsonian syndrome or untreated major depression, since interventions are available to address these causes of negative symptoms [II].

    Most patients who develop schizophrenia and related psychotic disorders are at very high risk of relapse in the absence of antipsychotic treatment. Unfortunately, there is no reliable indicator to differentiate the minority who will not, from the majority who will relapse with drug discontinuation. It is important to discuss with the patient the risks of relapse versus the long-term potential risks of maintenance treatment with the prescribed antipsychotic [I]. If a decision is made to discontinue antipsychotic medication, additional precautions to minimize the risk of a psychotic relapse is warranted. Educating the patient and family members about early signs of relapse, advising them to develop plans for action should these signs appear, and encouraging the patient to attend outpatient visits on a regular basis are warranted [I]. Indefinite maintenance antipsychotic medication is recommended for patients who have had multiple prior episodes or two episodes within 5 years [I]. In patients for whom antipsychotic medications have been prescribed, monitoring for signs and symptoms of impending or actual relapse is recommended [I].

    Adjunctive medications are commonly prescribed for comorbid conditions of patients in the stable phase. Comorbid major depression and obsessive-compulsive disorder may respond to antidepressant medications [II]. Mood stabilizers may also address prominent mood lability [II]. Benzodiazepines may be helpful for managing anxiety and insomnia during the stable phase of treatment [II].

    In assessing treatment resistance or partial response, it is important to carefully evaluate whether the patient has had an adequate trial of an antipsychotic medication, including whether the dose is adequate and whether the patient has been taking the medication as prescribed. An initial trial of 4–6 weeks generally is needed to determine if the patient will have any symptomatic response, and symptoms can continue to improve over 6 months or even longer periods of antipsychotic treatment [II]. Given clozapine’s superior efficacy, a clozapine trial should be considered for a patient who has had no response or partial and suboptimal response to two trials of antipsychotic medication (including at least one second-generation agent) or for a patient with persistent suicidal ideation or behavior that has not responded to other treatments [I].

    A number of psychosocial treatments have demonstrated effectiveness during the stable phase. They include family intervention [I], supported employment [I], assertive community treatment [I], skills training [II], and cognitive behaviorally oriented psychotherapy [II]. In the same way that psychopharmacological management must be individually tailored to the needs and preferences of the patient, so too should the selection of psychosocial treatments [I]. The selection of appropriate psychosocial treatments is guided by the circumstances of the individual patient’s needs and social context [II].

    Interventions that educate family members about schizophrenia are needed to provide support and offer training in effective problem solving and communication, reduce symptom relapse, and contribute to improved patient functioning and family well-being [I]. The Program for Assertive Community Treatment (PACT) is a specific model of community-based care that is needed to treat patients who are at high risk for hospital readmission and who cannot be maintained by more usual community based treatment [I]. Persons with schizophrenia who have residual psychotic symptoms while receiving adequate pharmacotherapy also may be offered cognitive behaviorally oriented psychotherapy [II].

    Supported employment is an approach to improve vocational functioning among persons with various types of disabilities, including schizophrenia, and should be made available [I]. The evidence-based supported employment programs that have been found effective include the key elements of services focused on competitive employment, eligibility based on the consumer’s choice, rapid job search, integration of rehabilitation and mental health care, attention to the consumer’s preferences, and time unlimited and individualized support.

    Social skills training may be helpful in addressing functional impairments with social skills or activities of daily living [II]. The key elements of this include behaviorally based instruction, modeling, corrective feedback, and contingent social reinforcement.

    Treatment programs need to combine medications with a range of psychosocial services to reduce the need for crisis-oriented hospitalizations and emergency department visits and enable greater recovery [I].

  3. Other Specific Treatment Issues
    1. First episode

      It is important to treat schizophrenia in its initial episode as soon as possible [II]. When a patient presents with a first-episode psychosis, close observation and documentation of the signs and symptoms over time are important because first episodes of psychosis can be polymorphic and evolve into a variety of specific disorders (e.g., schizophreniform disorder, bipolar disorder, schizoaffective disorder) [I]. Furthermore, in persons who meet the criteria for being prodromally symptomatic and at risk for psychosis in the near future, careful assessment and frequent monitoring are recommended until symptoms remit spontaneously, evolve into schizophrenia, or evolve into another diagnosable and treatable mental disorder [III]. The majority of first-episode patients are responsive to treatment, with more than 70% achieving remission of psychotic signs and symptoms within 3–4 months and 83% achieving stable remission at the end of 1 year. First episode patients are generally more sensitive to the therapeutic effects and side effects of medications and often require lower doses than patients with chronic schizophrenia. Minimizing risk of relapse in a remitted patient is a high priority, given the potential clinical, social, and vocational costs of relapse [I]. Family members are especially in need of education and support at the time of the patient’s first episode [I].

    2. Negative symptoms

      Treatment of negative symptoms begins with assessing the patient for syndromes that can cause the appearance of secondary negative symptoms [I]. The treatment of such secondary negative symptoms consists of treating their cause (e.g., antipsychotics for primary positive symptoms, antidepressants for depression, anxiolytics for anxiety disorders, or antiparkinsonian agents or antipsychotic dose reduction for extrapyramidal side effects) [III]. If negative symptoms persist, they are presumed to be primary negative symptoms of the deficit state. There are no treatments with proven efficacy for primary negative symptoms.

    3. Substance use disorders

      Nearly one-half of patients with schizophrenia have comorbid substance use disorders, excluding nicotine abuse/dependence, which itself exceeds 50% in prevalence in this group. The goals of treatment for patients with schizophrenia who also have a substance use disorder are the same as those for treatment of patients with schizophrenia without comorbidity but with the addition of the goals for the treatment of substance use disorders (e.g., harm reduction, abstinence, relapse prevention, and rehabilitation). A comprehensive integrated treatment model is recommended in which the same clinicians or team of clinicians provide treatment for schizophrenia as well as treatment of substance use disorders [III]. This form of treatment features assertive outreach, case management, family interventions, housing, rehabilitation, and pharmacotherapy. It also includes behavioral interventions for those who are trying to attain or maintain abstinence and a stage-wise motivational approach for patients who do not recognize the need for treatment of a substance use disorder.

    4. Depression

      Depressive symptoms are common at all phases of schizophrenia. A careful differential diagnosis that considers the contributions of side effects of antipsychotic medications, demoralization, the negative symptoms of schizophrenia, and substance intoxication or withdrawal is recommended [I]. Depressive symptoms that occur during the acute psychotic phase usually improve as patients recover from the psychosis. There is also evidence to suggest that depressive symptoms are reduced by antipsychotic treatment, with comparison trials finding that second-generation antipsychotics may have greater efficacy for depressive symptoms than first-generation antipsychotics [II]. Antidepressants may be added as an adjunct to antipsychotics when the depressive symptoms meet the syndromal criteria for major depressive disorder or are severe, causing significant distress or interfering with function [II].

    5. Suicidal and aggressive behaviors

      Suicide is the leading cause of premature death among patients with schizophrenia. Some risk factors for suicide among patients with schizophrenia are the same as those for the general population: male gender, white race, single marital status, social isolation, unemployment, a family history of suicide, previous suicide attempts, substance use disorders, depression or hopelessness, and a significant recent adverse life event. Specific demographic risk factors for suicide among persons with schizophrenia are young age, high socioeconomic status background, high IQ with a high level of premorbid scholastic achievement, high aspirations and expectations, early age at onset/first hospitalization, a chronic and deteriorating course with many relapses, and greater insight into the illness.

      Despite identification of these risk factors, it is not possible to predict whether an individual patient will attempt suicide or die by suicide. It is important to consider suicide risk at all stages of the illness and to perform an initial suicide risk assessment and regular evaluation of suicide risk as part of each patient’s psychiatric evaluation [I]. There is evidence to suggest that both first- and second-generation antipsychotic medications may reduce the risk of suicide. However, clozapine is the most extensively studied and has been shown to reduce the rates of suicide [II] and persistent suicidal behavior [I].

      During a hospitalization, use of suicide precautions and careful monitoring over time for suicidal patients are essential [I]. Upon discharge, the patient and the family members may be advised to look for warning signs and to initiate specific contingency plans if suicidal ideation recurs [I]. After a recent discharge from the hospital, a higher frequency of outpatient visits is recommended, and the number of visits may need to be increased during times of personal crisis, significant environmental changes, heightened distress, or deepening depression during the course of illness [III].

      A minority of patients with schizophrenia have an increased risk for aggressive behavior. The risk for aggressive behavior increases with comorbid alcohol abuse, substance abuse, antisocial personality, or neurological impairment. Identifying risk factors for aggressive behavior and assessment of dangerousness are part of a standard psychiatric evaluation [I].

  1. Treatment Settings and Housing Options

    Patients with schizophrenia may receive care in a variety of settings. In general, patients should be cared for in the least restrictive setting that is likely to be safe and to allow for effective treatment [I]. Indications for hospitalization usually include the patient’s being considered to pose a serious threat of harm to self or others or being unable to care for self and needing constant supervision or support [I]. Other possible indications for hospitalization include general medical or psychiatric problems that make outpatient treatment unsafe or ineffective [III] or new onset of psychosis [III]. Efforts should be made to hospitalize such patients voluntarily [I].

    Treatment programs that emphasize highly structured behavioral techniques, including a token economy, point systems, and skills training that can improve patients’ functioning, are recommended for patients with treatment-resistant schizophrenia who require long-term hospitalization [I].

    When it is uncertain whether the patient needs to be hospitalized, alternative treatment in the community, such as day hospitalization, home care, family crisis therapy, crisis residential care, or assertive community treatment, should be considered [III]. Day hospitalization can be used as an immediate alternative to inpatient care for acutely psychotic patients or used to continue stabilization after a brief hospital stay [III].

    Day treatment programs can be used to provide ongoing supportive care for marginally adjusted patients with schizophrenia in the later part of the stabilization phase and the stable phase of illness, and such programs are usually not time-limited [III]. The goals are to provide structure, support, and treatment to help prevent relapse and to maintain and gradually improve the patient’s social functioning [III].


An algorithm is provided in the original guideline document for somatic treatment of schizophrenia.



The evidence base for practice guidelines is derived from two sources: research studies and clinical consensus. Where gaps exist in the research data, evidence is derived from clinical consensus, obtained through extensive review of multiple drafts of each guideline.



  • American Psychiatric Association. Practice guideline for the treatment of patients with schizophrenia. 2nd ed. Arlington (VA): American Psychiatric Association; 2004 Feb. 114 p. [1391 references]


Not applicable: The guideline was not adapted from another source.


1997 (revised 2004 Feb)


American Psychiatric Association - Medical Specialty Society


American Psychiatric Association (APA)


Work Group on Schizophrenia
Steering Committee on Practice Guidelines


Work Group Members: Anthony F. Lehman, MD, MSPH (Chair); Jeffrey A. Lieberman, MD (Vice-Chair); Lisa B. Dixon, MD, MPH; Thomas H. McGlashan, MD; Alexander L. Miller, MD; Diana O. Perkins, MD, MPH; Julie Kreyenbuhl, PharmD, PhD, Consultant

Steering Committee on Practice Guidelines Members: John S. McIntyre, MD (Chair); Sara C. Charles, MD (Vice-Chair); Kenneth Altshuler, MD; Ian Cook, MD; C. Deborah Cross, MD; Lisa Mellman, MD; Louis Alan Moench, MD; Grayson Norquist, MD; Stuart W. Twemlow, MD; Sherwyn Woods, MD, PhD; Joel Yager, MD

Consultants and Liaisons: Sheila Hafter Gray, MD (Liaison); Kathleen Askland, MD (Liaison); Rupang Pandya, MD (Liaison); Konasale Prasad, MD (Liaison); Robert Johnston, MD (Area I); James Nininger, MD (Area II); Roger Peele, MD (Area III); Daniel J. Anzia, MD (Area IV); R. Scott Benson, MD (Area V); Lawrence Lurie, MD (Area VI); R. Dale Walker, MD (Area VII)

Staff: Robert Kunkle, MA, Senior Program Manager; Althea Simpson, MBA, Project Coordinator; Laura J. Fochtmann, MD, Medical Editor; Claudia Hart, Director, Department of Quality Improvement and Psychiatric Services; Darrel Regier, MD, MPH, Director, Division of Research


This practice guideline has been developed by psychiatrists who are in active clinical practice. In addition, some contributors are primarily involved in research or other academic endeavors. It is possible that through such activities some contributors have received income related to treatments discussed in this guideline. A number of mechanisms are in place to minimize the potential for producing biased recommendations due to conflicts of interest. The guideline has been extensively reviewed by members of the American Psychiatric Association (APA) as well as by representatives from related fields. Contributors and reviewers have all been asked to base their recommendations on an objective evaluation of the available evidence. Any contributor or reviewer who has a potential conflict of interest that may bias (or appear to bias) his or her work has been asked to notify the APA Department of Quality Improvement and Psychiatric Services. This potential bias is then discussed with the work group chair and the chair of the Steering Committee on Practice Guidelines. Further action depends on the assessment of the potential bias.


This is the current release of the guideline.

This guideline updates a previous version:

American Psychiatric Association (APA). Practice guideline for the treatment of patients with schizophrenia. Washington (DC): American Psychiatric Press, Inc; 1997. 146 p.

Practice guideline for the treatment of patients with schizophrenia. American Psychiatric Association (APA). Am J Psychiatry 1997 Apr;154(4 Suppl):1-63.


Electronic copies: Available in Portable Document Format (PDF) from the American Psychiatric Association (APA) Web site.

Print copies: Available from the American Psychiatric Press, Inc (APPI), 1400 K Street NW, Washington, DC 20005; (202) 682-6262; (800) 368-5777; fax (202) 789-2648.


The following is available:

  • American Psychiatric Association practice guideline development process. Washington, DC: APA, 2004.

Electronic copies: Available in Portable Document Format (PDF) from the American Psychiatric Association (APA) Web site.

Print copies: Available from the American Psychiatric Press, Inc (APPI), 1400 K Street NW, Washington, DC 20005; (202) 682-6262; (800) 368-5777; fax (202) 789-2648.

Additionally, a continuing medical education (CME) course is available online at the American Psychiatric Association Web site.


None available


This summary was completed by ECRI on December 1, 1998. The information was verified by the guideline developer on February 3, 1999. This NGC summary was updated on July 8, 2004. The information was verified by the guideline developer on August 2, 2004. This summary was updated by ECRI on August 15, 2005, following the U.S. Food and Drug Administration advisory on antidepressant medications. This summary was updated by ECRI on January 18, 2006, following the U.S. Food and Drug Administration advisory on Clozaril (clozapine). This summary was updated by ECRI Institute on October 2, 2007, following the U.S. Food and Drug Administration (FDA) advisory on Haloperidol. This summary was updated by ECRI Institute on November 6, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs. This summary was updated by ECRI Institute on January 10, 2008, following the U.S. Food and Drug Administration advisory on Carbamazepine. This summary was updated by ECRI Institute on July 25, 2008, following the U.S. Food and Drug Administration advisory on Antipsychotics.


This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.



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