Formulating treatment plans

Initial planning Reasonable, effective treatment plans can be devised around the first-line use of standard antipsychotics and at present, these should be the initial choice in the majority of cases. However, caution is urged with the routine use of high-potency compounds, especially in first-episode patients and those in relapse who have not been receiving medication for some time.

Low-potency regimens

Foundation recommendations With disturbance in both non-specific and behavioural domains, a low-potency drug is a reasonable first choice for the initial treatment plan:

• in the drug-naive or frail, chlorpromazine 50 mg twice daily and 100 mg at night

• in those with prior exposure, chlorpromazine 100 mg three times daily or 100 mg twice daily and 150 mg at night.

Added flexibility 'As-required' prescriptions allow nursing colleagues to intervene at their discretion, in the face of increasing disturbance. These should be carefully prescribed with indications, maximum frequencies, dosages, and modes of administration written up separately and unambiguously. A major advantage of 'as-required' prescriptions is to inform the judgement about how far short initial treatment recommendations fall from practical requirements, and information on the use of this component of the plan should be incorporated into each revision. In order to avoid polypharmacy, choices of drug for 'as-required' prescription should, as far as possible, be limited to additional doses of the initial compound.

Adjunctive medications If the initial plan achieves less than was anticipated, it is important to consider adding adjunctive treatments, in order to avoid over-rapid increments in antipsychotic doses. Benzodiazepines are best in this situation.

High-potency regimens

Foundation recommendations Initial plans with these drugs might comprise the following:

• in the drug naive, haloperidol 1.5 to 2 mg twice daily

• in those previously exposed, haloperidol 2.5 to 3 mg twice daily.

Added flexibility It is important with high-potency regimens to be circumspect about the prescription of 'as-required' doses. Additional doses of one's first-choice drug or single doses of another high-potency compound will inevitably lead to rapid dose escalation and the likelihood of neurological adverse effects. A benzodiazepine should again be considered as an alternative.

Fifty per cent of acute dystonias present within 3 days of the start of treatment or dose increments, and features of akathisia can be evident even after single, especially parenteral, doses of high-potency compounds.(5) Prescribing an 'as-required' anticholinergic does allow experienced nursing staff to intervene immediately should such features emerge, although this should only be implemented after medical confirmation of the diagnosis.

Adjunctive medications Reliance on benzodiazepines to achieve early, acute-phase treatment goals may be greater if one's initial plan incorporates a high-potency antipsychotic, as the low introductory doses recommended here may be inadequate to improve sleep and ease anxiety/agitation as swiftly as is ideal.

Where neither non-specific symptomatology nor behavioural disturbance is prominent, advocacy for any particular drug type is more problematic. While the use of standard compounds as the first-line treatment of acute schizophrenic episodes is advocated, there are two scenarios in which new-generation drugs should be considered:

1. those first-episode patients in whom it is felt particularly important to minimize the risk of adverse effects, especially sedation and the unpleasant subjective experience of neurological adverse effects;

2. patients in relapse who have been poorly tolerant, especially of extrapyramidal symptomatology, in the past.

Revision Monitoring response to initial treatment decisions involves bringing together information from nursing colleagues, prescription data, mental state examination, and assessment of non-target effects, including extrapyramidal status. Initial treatment plans should be reviewed frequently—a key element in fostering engagement and compliance as well as in refining treatment recommendations.

The markers of early progress in treatment are stabilization and, over several days, containment of non-specific affective symptomatology, improvement in nocturnal sleep without undue daytime drowsiness, and control of overactive, disorganized, and potentially confrontational behaviour.

There are two temptations to avoid in revising early treatment plans. The first is changing drug prematurely and the second is introducing polypharmacy. While intolerance or patient pressure may force an early change of antipsychotic, it is in general important to give each drug an adequate trial, which may take several weeks, while adding other antipsychotics to the foundation drug will increase the antipsychotic 'load' and the neurological risks. Rather than go down either of these roads, it is better to rely on adjunctive medications to temporarily contain difficult situations.

The post-acute phase Goals

The post-acute phase is characterized by returning stability. The goals now are as follows:

1. consolidation of clinical improvements

2. rationalization of the treatment regimen

3. resocialization.

All schizophrenic symptomatology does not resolve at the same rate and the first signs of improvement should not be taken as evidence that the tide has conclusively turned. Global improvements evident over the broad range of domains must be shown to deepen into specific improvements in particular symptomatology. Furthermore, improvements evident in the ward environment need to be shown to generalize to the patient's routine situation. Although there is no evidence that rationalizing and simplifying the treatment plan contributes to enhanced compliance, (107) this is intuitively sound. This is also the period when resocialization, and if necessary rehabilitation, should be commenced, and secondly, the issue of longer-term treatment raised.

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