DGPPN guideline for the treatment of schizophrenia from 2005

The schizophrenia is a cosmopolitan disease and enters a person at risk on the order of 1% over the entire life time. Most patients fall ill before the age of 35. The characteristic features of the disease include the so-called first -line symptoms according to Kurt Schneider. The cause of the disease is unknown. The onset of the disease is usually preceded by a prodromal phase lasting several years . This article summarizes all of the treatments for schizophrenia based on the DGPPN guide.

DGPPN guidelines for the treatment of schizophrenia

The German Society for Psychiatry, Psychotherapy and Neurology (DGPPN) issues guidelines for the treatment of mental disorders. The first volume of the guidelines dealt with the topic of schizophrenia and was published in 1998. The current, detailed version of the “S3 Practice Guideline in Psychiatry and Psychotherapy” for the treatment of schizophrenia was published in 2006 and summarizes the status of all scientific therapy research on schizophrenia up to the end of 2004 . The recommendations of the guideline were developed as evidence-based consensus guidelines. The guideline is not a guideline in the professional sense, which prescribes a binding rule, but a statement that serves as information. It is a therapy guideline that meets all the requirements of a systematic creation:

Evidence-based medicine ,
Clinical algorithm,
Formal consensus finding,
Decision analysis and outcome analysis in terms of health goals.

Authors

The responsible editors of the guidelines are Wolfgang Gaebel ( University of Düsseldorf ) and Peter Falkai ( University of Saarland ). The authors' expert group includes 11 university professors. The consensus group includes 19 people, including six doctors, employees of non-medical therapists ( social work , occupational therapy , nursing and clinical psychology ), a representative of the hospital management, a representative of the Federal Rehabilitation Working Group , two patient representatives (Federal Association of Psychiatry Experienced and Action Mentally Ill) and one representative the relatives' associations. For the consensus round, representatives of the local over were welfare agency and the Society for Family Medicine invited. However, they did not take part in the consensus process for drawing up the guidelines. Two medical representatives from the scientific medical societies moderated the consensus process.

Methods

Employees from the DGPPN's quality assurance department formed the project group that took over the management. The expert group drafted the individual chapters of the guidelines. In the consensus rounds, each recommendation of the expert group was voted on. The recommendations were based on a selected and structured literature research. A total of 580 scientific studies were evaluated. After the guidelines had been drawn up, they were externally assessed and published on the Internet in order to give experts and laypeople the opportunity to comment before completing the work. In order to avoid conflicts of interest, representatives of the pharmaceutical industry were excluded from drawing up the guidelines. The guidelines are valid until 2008. When drafting, existing guidelines, mainly from English-speaking countries, were taken into account. The guideline was fully funded by the DGPPN. The method report of the S3 guideline can be viewed on the Internet.

Levels of evidence and strengths of recommendation

In the guidelines of the DGPPN, a treatment method receives an evaluation in terms of a recommendation with three strengths (grade A, B and C). The recommendation is based on evidence criteria. For example, if a treatment method was judged to be effective in a meta-analysis and at least three randomized controlled trials were combined in this study, then the treatment method receives the highest grade of recommendation (grade A).

Levels of evidence

The levels of evidence are defined as follows:

Ia: meta-analysis of at least three randomized controlled trials (RCTs)
Ib: at least one randomized controlled trial (RCT) or meta-analysis of fewer than three RCTs
IIa: at least one controlled, non-randomized study with a methodologically high-quality design
IIb: at least one quasi-experimental study with a methodologically high-quality design
III: at least one non-experimental descriptive study (comparative study, correlation study, case series )
IV: Report / recommendations from expert committees, clinical experience of recognized authorities.

Recommendation strength

Based on the available evidence derived from the analysis of the scientific studies published by the end of 2004, the strength of recommendation is based on the following rules:

A. Grade: A treatment method receives recommendation level A if studies of category Ia or Ib are available for the method.
B. Grade: A treatment method receives recommendation level B if studies of category IIa, IIb or III are available for the method. (If a category I study is available from which the recommendation for a method must be extrapolated, then it is also given the recommendation strength B)
C. Grade: A treatment method receives recommendation level C if studies of category IV are available for the method. (If studies of category IIa, IIb or III are available from which the recommendation for a method must be extrapolated, then it is also given the recommendation strength C)

Good Clinical Practice

If there are no experimental scientific studies for a treatment method, if these are not possible or not aimed at, but the method is still generally accepted and an agreement on the method could be reached within the consensus group, this method is recommended as Good Clinical Practice ( GCP).

credentials

The definition of the levels of evidence and the rules for the strength of recommendations were drawn up by the US Agency for Health Care Policy and Research of the US Department of Health and are also based on the British schizophrenia guidelines of the National Institute for Clinical Excellence (NICE).

Content of the guidelines

The guidelines for the treatment of schizophrenia are available in three versions: a detailed long version, a clear short version and in the form of easy-to-remember algorithms. The short version of the guideline can be viewed on the Internet. They are divided into eight subgroups:

general basics

In the general principles of the Schizophrenia treatment guideline, the aim of this guideline is defined as an aid to decision-making. They are not binding guidelines for the treatment of schizophrenia.

The definition of the subject of the guideline, schizophrenia, is summarized using the ICD criteria.

The generally recognized data on epidemiology are presented: Lifetime prevalence worldwide between 0.5 and 1.6%, preferred age of onset between 15 and 35 years of age, men become ill 3 to 4 years earlier than women, the lifetime risk is the same for both sexes , Patients with schizophrenia have a lower life expectancy.

Regarding the course and prognosis, the initial prodromal phase is emphasized and the fact that 20% of patients can be completely cured is emphasized. The main risk factors are: family history, male gender, delayed onset of illness, cognitive dysfunction, low premorbid intelligence, negative symptoms, poor premorbid social adjustment, lack of stable partner relationships, psychosocial stress, stressful family climate, birth complications and ethnic minority status.

The vulnerability-stress-coping model of schizophrenia based on Zubin is assumed as the etio - pathogenetic basic concept.

Regarding the costs of the disease, it is noted that around 30% of the treatment costs arise in the first year of the disease and that the total costs of the disease are comparable to those of widespread somatic diseases (in Germany up to € 14,000 per patient and year).

Diagnostics and classification

The diagnosis of the disease should be based on operationalized criteria. The following key symptoms are assumed:

1. Thoughts uttered, inspired, withdrawn or spread.
2. Mania for control and influence, feeling of what has been done.
3. Commentary or dialogical voices.
4. Persistent, culturally inappropriate, or completely unrealistic delusion.
5. Persistent hallucinations of any sensory modality.
6. Thoughts off.
7. Catatonia.
8. Negative symptoms.

The following rule applies to the diagnosis:

There must be at least one distinct symptom of group 1 to 4 or
There are at least two symptoms in groups 5 to 8.
Symptoms must be uninterrupted for at least a month.
Organic brain diseases, intoxication or substance withdrawal must be excluded.

When making a diagnosis, schizophrenia should be distinguished from other psychotic disorders. Physical, psychological and technical examinations should be carried out to secure the diagnosis and to exclude concomitant diseases. The diagnostic guidelines have no recommendation grade due to the study situation. They are considered GCP.

General therapy

The recommendations on general treatment principles include an overall treatment plan within the framework of a multi-professional team and phase-specific treatment goals (multimodal social-psychiatric treatment concept). The phase-specific treatment goals relate to the therapy goals in the acute phase, in the post-acute stabilization phase and in the remission phase of the disease. There are no scientific studies on the general treatment principles. They are therefore considered GCP.

Pharmacological and other somatic treatments

General recommendations on pharmacotherapy relate to integrating drug therapy into an overall treatment plan, educating the patient, and establishing a clinical target syndrome. Other somatic procedures, such as ECT and rTMS, have a narrow application specification (indication).

The recommendations for drug therapy are divided into the groups of

Phase-specific therapy,
Drug resistance and
Dealing with side effects.

Phase-specific therapy includes treatment of the acute phase, relapse prevention and long-term therapy. In the case of drug resistance, recommendations are made regarding conversion, combination treatment and the use of ECT. When dealing with side effects, the aspects of extrapyramidal side effects, the undesirable metabolic effects of neuroleptics and the control examinations during long-term therapy are discussed.

In drug therapy, there are a number of Grade A recommendations. They include:

Antipsychotics are the drug of choice in the treatment of acute schizophrenic episodes, in relapse prevention and in long-term therapy.
Antipsychotics should be given continuously.
Atypical antipsychotics should be preferred, especially if they have cognitive impairments.
The selection of the recommended typical antipsychotics is very narrowly limited to four substances, for one case there is a dosage recommendation.

Psychotherapeutic interventions

Psychotherapeutic interventions in the treatment of schizophrenia include psychoeducation, cognitive behavioral therapy, family interventions, training of social skills, cognitive rehabilitation procedures, psychodynamic and psychoanalytic procedures, talk therapy, occupational therapy and other forms of therapy such as art and music therapy.

With regard to psychotherapeutic interventions in schizophrenia, the S3 guidelines provide the following recommendations with recommendation level A:

Cognitive behavioral therapy is effective in the prepsychotic prodromal phase and is recommended for persistent psychotic symptoms.
Working with family members reduces the likelihood of relapse.
The rehabilitation of cognitive deficits and psychoanalytic therapy methods are not effective in schizophrenia and are not recommended.

Help systems and sociotherapeutic interventions

The help systems and sociotherapeutic interventions concern:

Integrated community-based help systems,
Outpatient treatment by a specialist,
Transitional facilities,
Inpatient treatment,
Work reintegration.

Recommendation strength A is given:

A team-based community psychiatric treatment and the so-called case management,
The day clinic as an alternative to inpatient treatment,
The use of crisis intervention teams in the community environment and
Employment promotion.

Treatment under special conditions

Count to treatment under special conditions

Treatment of the initial prodromal phase,
The therapy of arousal states,
Treatment principles for suicidality,
The treatment of comorbidity, especially substance addiction and diabetes screening,
Advice to female patients regarding pregnancy and breastfeeding,
Gender issues and
Treatment of schizophrenia in old age.

There are only three recommendations for this area with recommendation grade A:

In states of agitation, lorazepam should be combined with an antipsychotic,
Clozapine should be given if the risk of suicide is greatly and continuously increased,
In the case of persistent depressive moods, additional drug antidepressant therapy should be carried out.

Treatment cost-effectiveness

Despite numerous studies, there is no study with evidence level Ia on the cost-effectiveness of the treatment of schizophrenia. The cost-effectiveness of atypical antipsychotics could no longer be replicated in numerous recent studies.

Summary

The S3 treatment guidelines for schizophrenia of the DGPPN reflect the status of scientific therapy research on schizophrenia up to and including 2004. The small number of recommendations with recommendation grade A is remarkable. It is below thirty out of 170 recommendations. Many Grade A recommendations are of a very general nature, for example that antipsychotics are the drug of choice and should be given continuously. There are only very few highly specific Grade A recommendations, such as the administration of clozapine for chronic suicidality or the dosage recommendation for haloperidol. Above all, this shows how difficult it is to conduct randomized controlled trials in the case of schizophrenia. However, it also shows that many measures are poorly investigated or not investigated at all (art therapy) or have little or no effect (psychoanalysis). It is evident that in addition to the question of the cost effectiveness of the treatment measures, the question of the selection of really effective procedures and the need for targeted therapy research also arise.

literature

R. Tandon, HA Nasrallah, MS Keshavan: Schizophrenia, “Just the Facts” 5. Treatment and prevention Past, present, and future. In: Schizophrenia Research. 122, 2010, pp. 1-23.

Individual evidence

↑ TO Jablensky et al.: Schizophrenia: Manifestations, incidence and course in different cultures. A World Health Organization ten-country study. In: Psychol. Med. (Monograph Suppl. 20). Cambridge University Press, 1992, ISBN 0-521-42328-7 .

↑ W. Gabel et al .: S3 practice guidelines in psychiatry and psychotherapy. Volume 1: Treatment guidelines for schizophrenia. Steinkopf, Darmstadt 2006, ISBN 3-7985-1493-3 .

↑ Method report of the S3 guideline ( memento of the original from March 1, 2011 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. (PdF; 420 kB) @1@ 2

↑ AHCPR. Acute pain management. AHCPR Publ. No. 92-0032: Feb. 1992. Rockville, MD.

^ National Institute for Clinical Excellence: Core Interventions in the Treatment of Schizophrenia. London 2003. UK National Health Service guideline. (Financing without support from the pharmaceutical industry)

↑ Short version of the guideline ( Memento of the original from March 4, 2016 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. (PdF; 409 kB) @1@ 2

[1] TO Jablensky et al.: Schizophrenia: Manifestations, incidence and course in different cultures. A World Health Organization ten-country study. In: Psychol. Med. (Monograph Suppl. 20). Cambridge University Press, 1992, ISBN 0-521-42328-7 .

[2] W. Gabel et al .: S3 practice guidelines in psychiatry and psychotherapy. Volume 1: Treatment guidelines for schizophrenia. Steinkopf, Darmstadt 2006, ISBN 3-7985-1493-3 .