Flowchart for the Consultant for the Pharmacotherapy of Schizophrenia

by David N. Osser, M.D.

Copyright Mental Health Connections, Inc. 1991-2003.

Caution: Do not use this flowchart to find treatment recommendations for patients. It is intended only as an overview of the topics covered. Answer the questions and read the associated texts which contain the evidence-supported discussion, reasoning, and analysis of alternatives.

                          Start
                            |
                            |
                            |
                 _______Diagnosis?_____
                |                      |  
       DSM-4 Schizophrenia,       Other Illness
        Schizoaffective or             |
     Schizophreniform disorder    Not covered by
                |                 this algorithm         
           Comorbid alcohol or
       substance abuse/dependence?
           |                 |
          Yes                No
           |                 |
 Treat abuse/dependence      |
           |                 |
       ____|______  Clinical situation__________________
       |                  |              |             |
First treatment         Acute        Agitation    Unsatisfactory
  with anti-        exacerbation     requiring     recovery on 
  psychotic?       or recurrence?    parenteral?  antipsychotic? 
      |                   |               |              | 
   Review         ____The cause?___   Haloperidol     (More #1)  
differential     |                 |  + lorazepam (12)       
 diagnosis   Breakthrough    Medication  
      |      on maintenance  discontinued or
      |      medication      taken irregularly.    
      |          |                 |
      |  Keep antipsychotic   ____Why?_____
      |      or change?      |             |
      |     |          |  Physician    Patient decided
      |     |          |  supported        |
      |   Keep      Change   |      Good alliance/insight 
      |           (More #1)  |   or good supervision available? 
      |                      |       Yes                    No
      |                      |        |                     |
      |                      |        |        Were side effects the main
      |                Previous recovery     reason for the poor alliance?
      |                  satisfactory?              No         Yes      
      |               |                 |           |           |
      |              No               Yes         Depot         |
      |               |                 |                       |
Try aripiprazole, olanzapine,        Were side effects          |
 quetiapine, risperidone,      a factor in discontinuation?     |
      or ziprasidone              |                    |        |
     (13-1,2,3,4,or 5)           No                   Yes       |
                                  |                    |        |
                          Restart previous   Try one of the five atypicals 
                          medication (07)          (13-1,2,3,4,or 5)   

       
                                                        


                     (More #1)
           ______Medication toxicity?_________ 
          |            |          |           |
  Anticholinergic?  Sedation?    None     Metabolic
          |            |          |     tremor present?   
    Reduce anti-       |        |           |
 cholinergic (155)  Taking    |     Find cause and
                   too many     |  eliminate if necessary (155-2) 
               sedating drugs?  |
                 |             |  |
                Yes           No  | 
                 |             |  |
 Taper offending drugs (01)  |  |
                               |  |
                               |  |
      Comment: Side effect assessment and management complete 
                                |                                
           Which antipsychotic is the patient taking now?
              |                                   |      
        Monotherapy with:                   Other regimen
   Chlorpromazine, Fluphenazine,                  |                 
   Haloperidol, Perphenazine,                 (More #3)  
   Thiothixene, Trifluoperazine                                                       
              |                                                            
Good trial in past with parkinsonian side effects?           
      |             |
     No            Yes                            
      |             |               
Park. now?---Yes----|--------------------- Comment: 
      |             |             Neuroleptic is bioavailable. 
     No             |                         |
      |             |          Marked parkinsonian side effects?
  Comment:       Comment:           |                  |     
Dose may not    Relying on         No                 Yes
be adequate.     history            |                  | 
      |             |       8 weeks on       Comment: Excessive dose
      |             |      neuroleptic?                |   
      |             |       |        |          Dose reduction
 On halo-           |      Yes       No        tried and failed?   
 peridol?           |       |        |          |             |
 |     |            |       |     Allow 8       No           Yes    
 No   Yes           |       |   weeks (121)     |             | 
 |     |          Comment:_ |               Try dose        Try dose   
 | Haloperidol    Neuroleptic         reduction (134-2)  reduction with              
 | level > 5?   resistant psychosis                    special techniques
 |   |     |          |                                      (134)                       
 |   No   Yes     Severe akathisia limiting dose?             
 |   |     |              |             |                        
Akathisia  |More #6)     Yes           No      
limiting                  |             |             
neuroleptic?              |         (More #4)           
 |       |                |           
 No      Yes              |        
 |       |                | 
 |       |   (More #5)    |
 |
Comment: Insufficient dose
              |
   _____Compliance type?____ 
   |            |           |
Taking       Taking      Taking
little      confirmed     some
   |            |           |
Treat as acute  |   Improve compliance (129-2) 
psychosis (129) |
                |       
          On haloperidol?
          |             |
          No           Yes
          |             | 
   Neuroleptic dose   | 
    = 1000mgs CPZ?    |
    |           |       |
   Yes          No      | 
    |           |       |
    |    Raise dose to criterion (150)     
    |
 Comment: Adequate trial of
 Standard Typical Neuroleptic
              |
          (More #4)


    
                              (More #3) 
                                    |
                         ___Which antipsychotic?___       
                         |          |             |
                        New     Clozapine  Older antipsychotic 
                  antipsychotic     |             |
                         |  Optimize (101)  Adequate trial?
                         |                  |            |             
                  Adequate trial?           No          Yes
                 |              |           |            |
                Yes             No        Complete       |
                 |              |       trial (107)   Comment:    
             Comment:        Complete              Adequate trial       
       Anticipate options   trial (103)              of Standard
                 |                               Typical Neuroleptic 
        Adequate trial of                                |
  Standard Typical Neuroleptic?                      (More #4)
    |                      |                                 
   No                     Yes                           
    |                      |                
 Tried >1 new    Comment: Clozapine criteria met       
 generation?               |         
 |         |       (More #4[Select])                                   
No        Yes      
 |         |            
 |      Try Standard Typical Neuroleptic (110-2)
 |  
Try another new generation (110) 

                          (More #4)
                              |
               Adequate trial of aripiprazole, 
olanzapine, quetiapine, risperidone or ziprasidone?____
                   |                                  |
                  Yes                                No
                   |                                  |
           Comment: Clozapine                       | 
             criteria met                           |
                  |                                   |
   Select your preference for pharmacotherapy_      |
  |            |           |           |       |      |
 Adjunctive  Older     Clozapine    Add 2nd    Different 2nd
 drug    antipsychotic     |     antipsychotic   generation 
  |            |    Clozapine safe?   |      antipsychotic (156)    
  |         Select         |         Add           |
  |           |||   Clozapine (116)  anti- 2nd generation (112-1,2,3,4,or 5) 
  |           |||                  psychotic
  |           ||Loxapine (113-2)
  |           |Pimozide (113-3)
Choose        Others (113-4)
| | | | | | | | |         
| | | | | | | | Manic -> lithium, etc. (117)
| | | | | | | Impulsive/violent -> lithium, etc. (117-2)
| | | | | | Depression/dysthymia -> antidepressants, etc. (117-3)
| | | | | Secondary depression -> imipramine, etc. (117-4)
| | | | Negative symptoms -> (various)(117-5)
| | | Obsessive-compulsive -> SSRI's, clomipramine, etc. (117-6)
| | Other anxiety disorders -> SSRI's, etc. (117-7)
| Impaired cognition -> (various) (117-8)
| None of the above: residual positive symptoms -> (misc. ideas) (117-9)
Organic psychosis
             |
    ______Choose likely etiology____________
   |             |            |             |
Alzheimers  Hallucinogen     TLE       Hypercalcemic 
   |           abuse          |          delirium
Anticonvulsants   |     Lithium, etc        |
 (118)            |        (118-3)       Pimozide
            Carbamazepine                (118-4) 
               (118-2) 

                     (More #5) 
                         |
            Akathisia thoroughly treated?
            |                          |               
           Yes                     No/Not sure
            |                          |
            |                Anticholinergic tried?
            |                |                   |     
            |               Yes                 No
            |                |                   |
            |       Beta blocker tried?   Try anticholinergic  
            |        |               |         (135)     
            |       Yes             No      
            |        |               |     
            |    Benzodiazepine  Beta blocker contraindicated? 
            |   + beta blocker?      |                   | 
            |    |          |         Yes                 No
            |   Yes        No          |                   |
            |    |          |       Benzodiazepine   Beta blocker (137)
            |    |     Try combi-       tried?              
            |    |    nation (138)   |          |  
            |    |                    Yes        No 
            |    |                     |          |
            |__Choose antipsychotic  |    Benzodiazepine (139)
                 |              |  
                New             |
            generation          |
                 |              |           
            (More #4)   Older neuroleptics (140)  
                          

                   (More #6)
                       |
     Comment: Inhibited neuroleptic activity
                       |
         Severe akathisia limiting dose? 
               |                |
              Yes              No
              |                 |
          (More #5)        Taking antiparkinsonian?
                              |                |
                             Yes              No
                              |                |
                    Antiparkinsonian is      |                            
                    treating akathisia?      |
                      |               |        | 
                     No              Yes       |
                      |               |        |               
     Recent dystonic reaction?   Continue    |   
        |                 |        antipar-    | 
       No                Yes       kinsonian   |
        |                 |           |        |
    Taper anti-     Comment:      |        |
    parkinsonian    Continue      |        |
    (149)           antipark-     |        | 
                      insonian      |        |
                               |      |        |
                              Haloperidol >20?            
                                |              |
                               No             Yes
                                |              |            
                  Raise haloperidol   Comment: Standard Typical  
                  to criterion (150)    Neuroleptics considered       
                                          exhaustively tried 
                                            ( More #4)