Schizophrenia Treatment Algorithm in Seven Easy Steps

If you're a doctor treating a patient for schizophrenia, the Physician Procedural Manual will help guide your clinical practice and make things a lot easier for you.

At each step of the way, always remember your three options: continue the present drug regimen, adjust the drug dose, or move on to another drug. Don't even think about taking your patient off drugs. The manual plainly states, "The schizophrenia algorithm contains no guidelines for antipsychotic medication discontinuation, which is anticipated to be a rare event in the typical mental health clinic patient population."

Your main task as a physician is to prescribe drugs. As a rule of thumb, it's always best to prescribe a new drug before its patent expires. For this reason, the new drugs called atypical antipsychotics are an excellent choice as first-line treatment.

Atypical antipsychotics cost twenty times more than older drugs, but cost is only one factor to consider when making a clinical judgement. Another factor is profit. With this in mind, schizophrenia can be treated in seven distinct stages, outlined below.

STAGE 1. Prescribe an atypical antipsychotic such as Zyprexa, Risperdal, or Seroquel. Some physicians will select a drug based on whichever sales rep last visited the office, but this is not recommended. Whatever brand you choose, if the patient shows little or no improvement after 4 weeks, go to the next stage.

STAGE 2. Switch to a different atypical antipsychotic. You may select a particular drug based on the quality of free ballpoint pens provided by the manufacturer, but this is not recommended. If results are unsatisfactory after a few weeks, go to the next stage.

STAGE 3. Switch to yet another atypical antipsychotic, or try a conventional antipsychotic such as Haldol for old times' sake. If progress remains unsatisfactory after a few more weeks, go to the next stage.

STAGE 4. Prescribe Clozaril. Since there's a 50-50 chance the patient will respond unfavorably to Clozaril, you may skip this stage and go directly to the next stage.

STAGE 5. Prescribe Clozaril in combination with another antipsychotic, or Clozaril in combination with electroshock. The manual says, "Almost all studies have shown beneficial effects of ECT for persistent psychotic states." The manual also says, "There are no controlled studies of ECT for schizophrenia in which number of treatments, duration of treatments, and electrode placement have been systematically evaluated." Therefore, if you're going to use electroconvulsive therapy on the patient, be sure to use it at least ten times, on both sides of the brain. If this proves unsuccessful, go to the next stage.

STAGE 6. Try one of the few remaining atypical antipsychotics you haven't tried yet. If results are satisfactory, that would be nice but it's not very likely at this stage, so go to the next stage.

STAGE 7. Prescribe any combination of two antipsychotics OR two antipsychotics plus electroshock OR two antipsychotics plus a mood stabilizer such as Depakote. Maintain this regimen for at least 12 weeks, if your patient lives that long.

Helpful hints for the clinician

In addition to prescribing drugs for schizophrenia, you may need to prescribe drugs for various "co-existing symptoms" of schizophrenia, such as sedatives for agitation, mood stabilizers for hostility, hypnotics for insomnia, antidepressants for depression, and so on.

You may also need to prescribe drugs to treat adverse side effects of drugs prescribed for schizophrenia, such as diabetes caused by Zyprexa or tremors caused by Risperdal, not to mention side effects of drugs prescribed for co-existing symptoms, such as hostility caused by antidepressants prescribed for depression and/or depression caused by mood stabilizers prescribed for hostility, and so on.

Before long, you'll be prescribing drugs to manage side effects of drugs prescribed to manage side effects, like a dog chasing its tail. The manual explains, "Using a medication to treat a side effect can result in additional adverse effects." This is why "side effects algorithms" are included in the manual as well. Don't worry. Just follow the manual.

Always remember to monitor your patient's progress. This is a routine task which may be performed in 5 minutes or less during regular office visits. Use the 8-point rating scale summarized below.

Does patient believe others have acted maliciously or with discriminatory intent?
Has patient had odd, strange or bizarre thoughts in the past 7 days?
Has patient had visions or seen things others cannot see?
Is patient's speech confused, vague, or disorganized?
When asked a question, does patient pause for long periods before answering?
Does patient's face remain blank or expressionless? ("Disregard changes in facial expression due to abnormal involuntary movements, such as tics and tardive dyskinesia," the manual advises.)
Does patient seem withdrawn or unsociable?
Does patient dress sloppily, or come to your office with poorly groomed hair? ("Do not rate grooming as poor if it is simply done in what one might consider poor taste," the manual advises.)

If the answer to all eight questions is no, your patient is probably not taking medications as prescribed. When noncompliance is a problem, the patient should be restrained if necessary and forcibly injected with a time-release antipsychotic. Maintain this regimen until patient gains insight into the need for treatment.

The cutting edge of science

This project was modeled after the Texas Implementation of Medication Algorithms. A distinguished panel of 25 Michigan experts very carefully replaced the word "Texas" with the word "Michigan" in all appropriate spots.

As new studies financed by drug companies discover ways to expand the market, and new products developed by drug companies enter the market, "this algorithm will be periodically revised and updated."

Funding for the Michigan Implementation of Medication Algorithms was provided by the Ethel and James Flinn Foundation of Detroit. The Michigan Pharmacy Quality Improvement Project, promoting the same agenda and with several of the same committee members, is funded by Eli Lilly, maker of Zyprexa. Lilly sales representatives carry a wide variety of ballpoint pens and other cool stuff.

If you think this is a joke, see the original document.

This article originally appeared in Ragged Edge Magazine.

"It is a matter of great importance that differences between parents of schizophrenic children and parents of normal children are more striking than are differences between schizophrenic patients and normal children serving as research controls." ~ Elliot Mishler and Nancy Waxler, Interaction in Families: An Experimental Study of Family Processes and Schizophrenia, 1968.

Latest studies from the Bonkers Institute:

Schizophrenia Treatment in Seven Easy Steps