Schizophrenia

and Other
Psychotic Disorders
Clinical Practice
Guideline
This guideline is informational in nature and is not intended
to be a substitute for professional clinical judgment.

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This document applies to MD-Individual Practice Association, Inc. (M.D. IPA), Optimum Choice, Inc. (OCI),
MAMSI Life and Health Insurance Company (MLH) and Alliance PPO, LLC (Alliance).

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Schizophrenia and Other Psychotic Disorders
Clinical Practice Guideline

Schizophrenia and Other Psychotic Disorders Clinical Practice Guideline

1. Differential Diagnosis of Schizophrenia.............................................................................................................................page 2

2. Start Medication.....................................................................................................................................................................page 2
3. Continuity of Care..................................................................................................................................................................page 2
4. Antipsychotic Treatment Algorithm – Acute Phase .........................................................................................................page 4
5. Algorithms for the Management of Side Effects During the Acute Phase ..................................................................page 5
6. Co-existing Symptoms Algorithms ....................................................................................................................................page 5
7. Antipsychotic Treatment Algorithm – Maintenance Phase ............................................................................................page 6

Page 1 of 6 Origin: 5/6/98 Reviewed/Revised Date: 10/03, 4/6/05

This document is proprietary to UnitedHealthcare or one of its companies and is not to be used, circulated, reproduced, copied or distributed in any
manner whatsoever without the prior specific written permission of an authorized company official.
Schizophrenia and Other Psychotic Disorders
Clinical Practice Guideline

I. Differential Diagnosis of Schizophrenia

Rule Out: Characteristics that Distinguish from Schizophrenia

Psychotic disorder due to a gener- Presence of an etiological medical condition

al medical condition, delirium or
dementia
Substance-induced psychotic dis- Psychotic symptoms are initiated and maintained by substance use or
order or delirium medication side effects
Schizoaffective disorder Significant mood symptoms are present for a substantial portion of the total
duration of the illness
Mood disorder with psychotic Psychotic symptoms occur exclusively during periods of mood disturbance
features
Schizophreniform disorder Duration of psychotic symptoms is between one and six months
Brief psychotic disorder Duration of psychotic symptoms is less than one month
Delusional disorder Non-bizarre delusions that occur in the absence of hallucinations,
disorganized speech or behavior, or negative symptoms
Pervasive developmental Early onset (e.g., before age three for autistic disorder); absence of prominent
disorders hallucinations or delusions
Schizotypal, schizoid or paranoid Absence of clear psychotic symptoms
personality disorders

McEvoy JP, Scheifler PL, Allen F (Eds.). 1999. The Expert Consensus Guideline Series: Treatment of Schizophrenia 1999. The Journal of Clinical
Psychiatry, 60 (Suppl.11)

II. Start Medication (see Antipsychotic Treatment Algorithm – Acute Phase)

III. Continuity of Care

1. Medication Management (see Algorithms for Management of Side Effects and Co-existing Symptoms During the
Acute Phase)
A. See patient weekly immediately following initiation of medication. Gradually reduce visit frequency to once a
month or less.
B. Routinely evaluate for and promptly respond to prodromal signs of relapse.
C. Monitor for and manage emerging metabolic side effects:
Baseline and every three months for the first six months and annually thereafter.
• Weight (BMI)
• Fasting Plasma Glucose
• Fasting Lipid Profile
D. Monitor for and manage other side effects:
• EPS
• Akathisia
• NMS
• Tardive dyskenisia

Page 2 of 6 Origin: 5/6/98 Reviewed/Revised Date: 10/03, 4/6/05

This document is proprietary to UnitedHealthcare or one of its companies and is not to be used, circulated, reproduced, copied or distributed in any
manner whatsoever without the prior specific written permission of an authorized company official.
Schizophrenia and Other Psychotic Disorders
Clinical Practice Guideline

2. Post Acute Hospitalization

A. Schedule first outpatient appointment to occur within seven days of discharge.
B. Arrange for crisis services.
C. Arrange for ongoing communication between all practitioners involved in the patient’s care.
D. Provide patient and family education on importance of treatment compliance and coping/life management
strategies.

3. Annual Screenings (Screenings should be administered more often than annually if clinically indicated.)
A. Urinalysis
B. Electrocardiogram
C. Dental Exam
D. Substance Abuse

4. Other Interventions to Consider Based on Individual Characteristics of Patient and Family

A. Individual Psychotherapy
B. Group Psychotherapy
C. Family Therapy
D. Education on or referrals to available community and advocacy services
E. Substance Abuse Treatment

Page 3 of 6 Origin: 5/6/98 Reviewed/Revised Date: 10/03, 4/6/05

This document is proprietary to UnitedHealthcare or one of its companies and is not to be used, circulated, reproduced, copied or distributed in any
manner whatsoever without the prior specific written permission of an authorized company official.
Schizophrenia and Other Psychotic Disorders
Clinical Practice Guideline

Antipsychotic Treatment Algorithm – Acute Phase

Notes:
1) The duration of a treatment trial is 3-8 weeks for patients with little or no response or 5-12 weeks for patients with
a partial response.
2) Any stage of this algorithm may be skipped depending upon clinical picture.
No history of Typical or History of Typical
Atypical Antipsychotic Baseline screening for Antipsychotic
medication failure metabolic issues medication failure

Positive Trial of Atypical Trial of Atypical Positive

response Antipsychotic drug Antipsychotic drug response

Non-response Non-response
to one drug to one drug

Trial of different Trial of different

Atypical Antipsychotic Atypical Antipsychotic Positive
Positive
drug or alter dose of Non-compliance drug or alter dose of response
response
current drug current drug

Non-response Trial of Haloperidol

Go to Maintenance Go to Maintenance
to two drugs Decanoate or
Phase Fluphenazine Non-response Phase
Decanoate to two drugs
Trial of different
Positive Atypical Antipsychotic
No response
response drug or alter dose of
current drug
Trial of different
Atypical Antipsychotic Positive
Non-response Trial of different
Atypical drug or drug or alter dose of response
to three drugs
alter dose of current drug
current drug
Positive Trial of Typical
response Antipsychotic drug

No
response

Clozapine + Augementing
Positive Agent (Typical or Atypical Partial
Antipsychotic, mood Clozapine Positive response
response response
stabilizer, ECT,
Antidepressant)

No No
response response

Combination of Atypical + Typical Antipsychotic drugs

or
Positive Combination of Atypical Antipsychotic drugs
response or
Combination of Atypical + Typical Antipsychotic drugs + ECT

Adapted from: Miller Al, Chiles JA, Chiles J, Crismon ML. TEXAS IMPLEMENTATION OF MEDICATION ALGORITHMS (TIMA):
Guidelines for Treating Schizophrenia: TIMA PHYSICIAN PROCEDURAL MANUAL (2000). page 8 (sect. 2-1).
Available at: http://www.mhmr.state.tx.us/centraloffice/medicaldirector/timasczman.pdf

Page 4 of 6 Origin: 5/6/98 Reviewed/Revised Date: 10/03, 4/6/05

This document is proprietary to UnitedHealthcare or one of its companies and is not to be used, circulated, reproduced, copied or distributed in any
manner whatsoever without the prior specific written permission of an authorized company official.
 Schizophrenia and Other Psychotic Disorders
Clinical Practice Guideline

Algorithms for the Management of Side Effects and Co-existing

Symptoms During the Acute Phase

Weight gain Hyperglycemia

EPS Akathisia NMS* Severe TD Mild TD 25% of Dyslipidemia
initial weight Diabetes Mellitus

Tactical
Interventions Anticholinergic Propranolol

No No
response response

Stop medications Go to next stage of

Stage Switch medications
Switch medications and refer to medical Switch medications Antipsychotic Treatment
Change Switch medications Clozapine and provide
specialist and/or Algorithm and/or refer
patient education to medical specialist
psychiatrist

*Note: NMS could be life-threatening.

Common Co-existing Symptoms During the Acute Phase**

Agitation/
Insomnia Depression Aggression/
Excitement
Hostility

Add PO/IM
Benzodiazepine PRN
(See Note) Add Benzodiazepine Add: Add Typical
or PRN SSRI Antipsychotic
PO/IM (See Note) Venlafaxine drugs first
Antipsychotic or Zolpidem PRN Bupropion
drug PRN Mirtazapine
No No
response No response: response
Use other drug (diagnosis ok,
indicated medical ok,
substance abuse ok)
Trazodone
Add Valproate
Go to next stage of and/or
Antipsychotic increase dose of
Go to next stage of
Treatment Algorithm current drug
Antipsychotic
Treatment Algorithm

**Note: Consider substance abuse issues when choosing medication to address co-existing symptoms.

Adapted from: Miller Al, Chiles JA, Chiles J, Crismon ML. TEXAS IMPLEMENTATION OF MEDICATION ALGORITHMS (TIMA):
Guidelines for Treating Schizophrenia: TIMA PHYSICIAN PROCEDURAL MANUAL (2000). page 9 (sect. 2-2).
Available at: http://www.mhmr.state.tx.us/centraloffice/medicaldirector/timasczman.pdf

Page 5 of 6 Origin: 5/6/98 Reviewed/Revised Date: 10/03, 4/6/05

This document is proprietary to UnitedHealthcare or one of its companies and is not to be used, circulated, reproduced, copied or distributed in any
manner whatsoever without the prior specific written permission of an authorized company official.
Schizophrenia and Other Psychotic Disorders
Clinical Practice Guideline

Antipsychotic Treatment Algorithm – Maintenance Phase

First episode with Multiple episodes and/or

symptom reduction persistent symptoms

12-24 months Long term (up to lifetime)

For elective dose reductions, gradually taper

at 2-4 week interval

No complications Non-compliance Relapse Tardive dyskenesia

or deterioration

Continue Consider Go to
effective depot Relapse Acute Relapse Switch to Atypical
treatment formulation Phase Antipsychotic drug

Adapted from: McEvoy JP, Scheifler PL, Allen E (eds.) 1999. The Expert Consensus Guideline Series: Treatment of Schizophrenia 1999.
The Journal of Clinical Psychiatry. 60 (Supp), guideline 6, page 16.

Page 6 of 6 Origin: 5/6/98 Reviewed/Revised Date: 10/03, 4/6/05

This document is proprietary to UnitedHealthcare or one of its companies and is not to be used, circulated, reproduced, copied or distributed in any
manner whatsoever without the prior specific written permission of an authorized company official.