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)