The recommendations that follow are those from the guideline's executive summary; detailed recommendations can be found in the original guideline document. Each recommendation is rated based on the level of the evidence and the grades of recommendation. Definitions of the grades of the recommendations (A, B, C, Good Practice Points) and level of the evidence (Level I-Level IV) are presented at the end of the Major Recommendations field.
A - Antipsychotic medications are the first-line treatment for psychotic symptoms. (Grade A, Level Ia)
A - Clozapine is not used as a first-line antipsychotic because of the risk of agranulocytosis. Its use is to be considered only after other antipsychotic medications prove inadequate; it can only be prescribed by a registered psychiatrist, and regular blood monitoring is mandatory. (Grade A, Level Ia)
A - Most patients respond to a daily antipsychotic dose of 300 to 1,000 chlorpromazine (CPZ) equivalents administered for a minimum of 6 weeks (Dixon, Lehman, & Levine, 1995). Patients with a first episode respond to lower doses than patients with recurrent episodes (McGorry, 1999; Remington, Kapur, & Zipursky, 1998; McEvoy, Hogarty, & Steingard, 1991). (Grade A, Level Ia)
GPP - Local Asian patients may respond to a lower daily antipsychotic dose. (GPP)
A - Maintenance dose is generally lower than that used in acute treatment, and the patient should continue with the lowest effective dose of antipsychotic medication. Dosages in excess of 600 CPZ equivalents/day should be avoided unless there are good clinical reasons (e.g., symptom control) for a higher dose (Dixon, Lehman & Levine, 1995). (Grade A, Level Ia)
B - Patients who have not responded to recommended antipsychotic medications should be considered for electroconvulsive therapy (ECT). (Grade B, Level III)
C - The prophylactic use of anticholinergic agents should be determined on a case-by-case basis, taking into account risk factors for both extrapyramidal side effects (EPSE) and anticholinergic side effects as well as the propensity of the antipsychotic medication to cause extrapyramidal side effects. (Grade C, Level IV)
B - Patients who experience persistent and clinically significant symptoms of anxiety and those with disruptive, dangerous, or assaultive behaviour should receive a trial of adjunctive benzodiazepines (Johns & Thompson, 1995). (Grade B, Level III)
B - Antidepressants should be considered for persistent depressive symptoms and should be prescribed with an antipsychotic to prevent worsening of psychosis (Black & Andresean, 1999). (Grade B, Level IIb)
B - Supportive individual and group psychotherapy in combination with medications can reduce relapses and enhance occupational and vocational functioning (Scott & Dixon, 1995). (Grade B, Level IIb)
A - Cognitive Behavioural Therapy is beneficial in reducing the symptoms (especially the positive symptoms) of schizophrenia (Garety, Fowler, & Kuipers, 2000). (Grade A, Level Ia)
A - Psychoeducation and family intervention can help reduce relapse rates. (Grade A, Level Ib)
A - Social skills training improves social adjustment and coping skills, thereby reducing relapse rates (Benton & Schroeder, 1990; Corrigan, 1991). (Grade A, Level Ib)
A - Vocational training is likely to benefit those who a) see competitive employment as a personal goal, b) have a history of prior competitive employment, c) have a minimal history of psychiatric hospitalization, and d) have been assessed to have good work skills (Lehman, 1995). (Grade A, Level Ib)
Definitions:
Grades of Recommendations
Grade A (evidence levels Ia, Ib): Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation.
Grade B (evidence levels IIa, IIb, III): Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation.
Grade C (evidence level IV): Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates absence of directly applicable clinical studies of good quality.
Good Practice Points: Recommended best practice based on the clinical experience of the guideline development group.
Levels of Evidence
Level Ia: Evidence obtained from meta-analysis of randomised controlled trials.
Level Ib: Evidence obtained from at least one randomised controlled trial.
Level IIa: Evidence obtained from at least one well-designed controlled study without randomisation.
Level IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study.
Level III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies.
Level IV: Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.
