The 2016 Royal Australian and New Zealand College of Psychiatrists guidelines for the management of schizophrenia and related disorders.

INTRODUCTION: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) clinical practice guidelines for the management of schizophrenia and related disorders provide evidence-based recommendations for optimising treatment and prognosis. This update to the 2005 RANZCP guidelines has a greater emphasis on psychosocial treatments, physical health comorbidities and vocational rehabilitation. Main recommendations: The guidelines advise a clinical staging approach and deliver specific recommendations for:•comprehensive treatment using second generation antipsychotic agents continuously for 2-5 years;•early treatment of comorbid substance use;•community treatment after initial contact, during crises and after discharge from hospital;•physical health monitoring and management of comorbidities, particularly metabolic health;•interventions to optimise recovery of social function and return to study or work; and•management of schizophrenia in specific populations and circumstances. Changes in management as a result of the guidelines: The guidelines provide benchmarks against which the performance of services and clinical teams can be assessed. Measuring treatment response and clinical outcome is essential. General practitioners have an important role, particularly in monitoring and reducing the high cardiovascular risk in this population. Clinical services focusing on early detection, treatment and recovery need continuous funding to be proactive in implementing the guidelines and closing the gap between what is possible and what actually occurs.

The 2016 RANZCP Guidelines for the Management of Schizophrenia and Related Disorders - what's next?

OBJECTIVES: The recently published RANZCP guidelines for schizophrenia and related disorders reviewed recent scientific evidence, and, where lacking, referred to clinical expertise to supply a template for raising the standard of care. This paper builds on the guidelines and recommends how they might be used to improve outcomes. METHODS: The guidelines call for evidence-based mental health policies, inclusive of mobilising affected families, communities and the public in support of policies that ensure better care and protect the wellbeing of people with severe mental disorders. The process of preparing the guidelines highlighted the limits of our scientific understanding of schizophrenia and shortcomings in the care currently provided. RESULTS: Writing the guidelines evinced the need for a culture of measuring outcomes and response to treatment, and harnessing such data to monitoring and optimising patient care. CONCLUSIONS: We recommend creation of a national case cohort for mental health research involving a collaborative network of clinical research centres, using the guidelines and generating scientific evidence for translation into clinical practice protocols that enable personalised treatment plans for patients and criteria for the performance of clinical services.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders.

OBJECTIVES: This guideline provides recommendations for the clinical management of schizophrenia and related disorders for health professionals working in Australia and New Zealand. It aims to encourage all clinicians to adopt best practice principles. The recommendations represent the consensus of a group of Australian and New Zealand experts in the management of schizophrenia and related disorders. This guideline includes the management of ultra-high risk syndromes, first-episode psychoses and prolonged psychoses, including psychoses associated with substance use. It takes a holistic approach, addressing all aspects of the care of people with schizophrenia and related disorders, not only correct diagnosis and symptom relief but also optimal recovery of social function. METHODS: The writing group planned the scope and individual members drafted sections according to their area of interest and expertise, with reference to existing systematic reviews and informal literature reviews undertaken for this guideline. In addition, experts in specific areas contributed to the relevant sections. All members of the writing group reviewed the entire document. The writing group also considered relevant international clinical practice guidelines. Evidence-based recommendations were formulated when the writing group judged that there was sufficient evidence on a topic. Where evidence was weak or lacking, consensus-based recommendations were formulated. Consensus-based recommendations are based on the consensus of a group of experts in the field and are informed by their agreement as a group, according to their collective clinical and research knowledge and experience. Key considerations were selected and reviewed by the writing group. To encourage wide community participation, the Royal Australian and New Zealand College of Psychiatrists invited review by its committees and members, an expert advisory committee and key stakeholders including professional bodies and special interest groups. RESULTS: The clinical practice guideline for the management of schizophrenia and related disorders reflects an increasing emphasis on early intervention, physical health, psychosocial treatments, cultural considerations and improving vocational outcomes. The guideline uses a clinical staging model as a framework for recommendations regarding assessment, treatment and ongoing care. This guideline also refers its readers to selected published guidelines or statements directly relevant to Australian and New Zealand practice. CONCLUSIONS: This clinical practice guideline for the management of schizophrenia and related disorders aims to improve care for people with these disorders living in Australia and New Zealand. It advocates a respectful, collaborative approach; optimal evidence-based treatment; and consideration of the specific needs of those in adverse circumstances or facing additional challenges.

Diabetes mellitus prevalence in Northland New Zealand schizophrenia patients on clozapine.

AIMS: Clozapine is a unique atypical anti-psychotic agent with best efficacy for treatment resistant schizophrenia compared to other agents, but with increased metabolic adverse effects. We sought to audit the prevalence of diabetes and pre-diabetes in Northland, New Zealand patients on clozapine. METHOD: We captured all 287 patients in Northland, New Zealand who were prescribed clozapine in September 2021 and obtained demographic, clinical and laboratory data. RESULTS: We discovered that 26.48% had diabetes (one patient type one, 75 type two diabetes) and 14.63% had pre-diabetes that developed after a median of six years' clozapine treatment. Diabetes prevalence is approximately 6% in the general population. NZ Maori made up 65.85% of the entire cohort (35.8% of the general population) and 85.53% of the diabetes patients. NZ Europeans represented most of the remaining 30.66% on clozapine, consistent with the largely bicultural ethnic mix of our region. Maori on clozapine were younger: mean age 42 years, compared to NZ Europeans, mean age 49 years. The average BMI was 37kg/m2 for Maori, 32 for Europeans (range 21-63, SD 8); there was a moderate relationship between clozapine use and increasing BMI (correlation coefficient of 0.74). For the diabetes patients, glycaemic control was overall suboptimal with a mean Hba1c of 66mmol/mol (range 41-117). CONCLUSIONS: Culturally appropriate, flexible and accessible services which integrate both the mental and physical health needs of Northland, New Zealand people with treatment-resistant schizophrenia on clozapine are required to reduce the 41% rate of dysglycaemia in this predominantly Maori group.

Ethnic comparisons of antipsychotic use in schizophrenia.

OBJECTIVE: The aim of the present study was to compare ethnic groups for antipsychotic prescribing in schizophrenia over 4.5 years. METHODS: All clinical files in three mental health services caring for outpatients in Auckland, New Zealand were reviewed at two time points (T1 =31 March 2000, T2 =31 October 2004). Data were collected (patient characteristics, diagnosis, antipsychotic treatment) and analysed at each time point. Adjustments were made for age and sex in the comparisons. After the first audit, feedback was provided to all three services. RESULTS: Differences in baseline prescribing were found between ethnic groups; rates of antipsychotic polypharmacy, second-generation antipsychotic (SGA) use, depot antipsychotic use, clozapine use and total antipsychotic dose. Overall five of the six prescribing outcome variables changed over the 4.5 years; only mean antipsychotic daily dose remained the same. Monotherapy rates increased in all ethnic groups with no difference found between them at T2 (85-86%). Similarly the prescribing variables of oral SGA use increased (83-87%), depots decreased (T2 =14-19%) and oral first-generation antipsychotics (FGAs) decreased (T2 =5-8%), all with no difference found between ethnic groups at T2. While clozapine use increased in all ethnic groups, a significant difference remained at T2; European, NZ Maori and Pacific all increased to 33-39%, but rates for Asian subjects increased only to 20%. The difference in mean daily antipsychotic dose between ethnic groups (122 mg day(-1) chlorpromazine equivalent (CPZe) at T1; 86 mg day(-1) CPZe at T2) reached statistical significance at both time points but overall the average dose (total mg day(-1)) for each group was within the usual clinical range. Adjustment for age and sex did not change the significance of any of the comparisons between ethnic groups. CONCLUSIONS: Most baseline differences in antipsychotic prescribing between ethnic groups resolved over time, with equal access for patients to recommended best practice with antipsychotic treatment in schizophrenia. Further work is required to look at differences in access to clozapine for Asian people.

Impact of audit and feedback on antipsychotic prescribing in schizophrenia.

OBJECTIVE: To examine the impact of audit and feedback on antipsychotic prescribing for schizophrenia outpatients over 4.5 years. METHODS: Clinical files in three mental health services caring for outpatients in Auckland, New Zealand were reviewed at two time-points (March 2000, October 2004). After the first audit, feedback was provided to all three services. Baseline prescribing variations between services were found for antipsychotic combinations and second-generation antipsychotic (SGA) prescribing, in particular clozapine. In two services audit and feedback continued with two interim reviews (October 2001, March 2003). Specific feedback and interventions targeting clozapine use were introduced in both services. No further audit or feedback occurred in the third service until the final audit. Data were collected (patient characteristics, diagnosis, antipsychotic treatment) and analysed at each audit. RESULTS: Three prescribing variables (antipsychotic monotherapy, SGA and clozapine use) were consistent with practice recommendations at the final audit (85.7%, 82.7% and 34.5% respectively) and had changed in the desired direction for all three services over the 4.5 years. At baseline there were differences between the three services. One service had baseline prescribing variables closest to recommendations, was actively involved in audit, and improved further. The second service, also actively involved in audit had baseline prescribing variables further from recommendations but improved the most. The service not involved in continuing audit and feedback made smaller changes, and SGA and clozapine use at endpoint were significantly lower despite at baseline being comparable to the service which improved the most. CONCLUSIONS: This study found audit and feedback to be an effective intervention in closing the gap between recommended and routine clinical practice for antipsychotic prescribing in schizophrenia.

Trends in antipsychotic prescribing in schizophrenia in Auckland.

OBJECTIVE: This study describes antipsychotic prescribing practices for outpatients with schizophrenia over a 3 year period in two large mental health catchment areas of Auckland. METHODS: All community files were reviewed at three time points. Patient characteristics, diagnosis and antipsychotic treatment information were recorded and analysed. RESULTS: Over the three time periods, the number of outpatients with a diagnosis of schizophrenia or schizoaffective disorder was stable. There was a marked change in the type of antipsychotic prescribed, with an 18.6% increase in atypical antipsychotics and a decrease in both intramuscular and oral typical antipsychotics. Clozapine was the most commonly prescribed antipsychotic in 2003 (35%). Despite the fact that polypharmacy was relatively low (14.6% in 2003), those receiving more than one antipsychotic had a greater likelihood of being prescribed a higher total daily dose. CONCLUSIONS: This study describes a change in antipsychotic prescribing towards recommended practice guidelines for the treatment of schizophrenia over a 3 year period.

The experiences of people with schizophrenia living in supported accommodation: a qualitative study using grounded theory methodology.

OBJECTIVE: This study aims to develop a detailed analysis of the subjective experiences of people with schizophrenia living in highly staffed supported accommodation. METHODS: Thirteen participants were audiotaped for one semistructured interview. The transcription and identified themes were discussed with the participants for feedback. Analysis of the interviews and feedback used grounded theory methodology. RESULTS: A unifying social theory was developed called 'A Way to Survive'. Survival experiences for these participants ranged from the life threatening to the mundane. The major categories linked to survival were; psychosis, identity, alienation, God/religion, family, basic life stuff and health services. CONCLUSIONS: A number of implications for service development and clinical practice were identified. Qualitative methodology for people with persistent psychotic symptoms allows for a depth and richness of information that may not be accessed using quantitative techniques. A number of difficulties in both collection and analysis arise from the presence of psychosis and further research in this area is required.

An audit of outpatient antipsychotic usage in the three health sectors of Auckland, New Zealand.

OBJECTIVE: To examine antipsychotic usage in outpatients in three community mental health centres. METHOD: A retrospective chart review was conducted for all outpatient files that were active in March 2000 at all community mental health services in Auckland (population 1.3 million). All patients prescribed an antipsychotic had information entered into a specifically designed computer software program. The antipsychotic, dose and route of administration were recorded. The diagnosis, number of hospitalizations, ethnicity and gender were also collected. RESULTS: 6558 community files were audited and 3254 people were prescribed antipsychotics; 3178 (97.6%) files had adequate information for study inclusion. The mean antipsychotic daily dose in chlorpromazine equivalents (CPZe) was 360 mg. Most of the population (76.6%) was prescribed an oral antipsychotic alone, 14.9% were prescribed depot antipsychotic only and 8.4% were on a depot and oral antipsychotic. The average daily dose prescribed for people on antipsychotic polypharmacy was 601 mg CPZe compared with 312 mg CPZe for those on a single antipsychotic. There were 2300 patients with schizophrenia (72.5% of cohort) and 585 patients with bipolar affective disorder (18.5%). The mean total daily dose in CPZe was significantly higher for schizophrenia than any other psychotic diagnoses. Regional analysis showed differences in the doses and type of antipsychotics prescribed; one health sector had significantly higher daily doses while another was significantly more likely to prescribe atypical antipsychotics and correspondingly fewer depot antipsychotics. CONCLUSIONS: There is a significant variation in the prescribing of antipsychotics across the three Auckland health sectors. The variation relates to dosage used, type of antipsychotics prescribed and effect of multiple antipsychotic prescribing. Combination therapy of more than one oral antipsychotic or a combination of oral and depot antipsychotics leads to a significant trend of higher doses in excess of best practice guidelines.