1 May 2004
Department of Defense - Federal Government Agency [U.S.]
Department of Veterans Affairs - Federal Government Agency [U.S.]
Veterans Health Administration - Federal Government Agency [U.S.]
Summary,

GUIDELINE OBJECTIVE(S)

* To promote evidence-based management of patients with psychoses/schizophrenia
* To identify the critical decision points in the management of patients with psychoses

TARGET POPULATION

Patients with psychoses or schizophrenia who are eligible for care In the Veterans Health Administration (VHA) or Department of Defense (DoD) health care delivery system

INTERVENTIONS AND PRACTICES CONSIDERED

Initial Screening

1. Assessment of suicide risk including detailed history and direct questioning
2. Establishing level of risk: imminent, short-term, or long-term
3. Assessment of risk for violence by evaluating history of previous violence, targeted individual in community, serious psychiatric illness, psychosocial illness, psychosocial disruption, history of violent suicide attempt, substance abuse, verbal abuse and hostility, history of poor adaptation to stress, and male gender
4. Assessment of risk for medical instability via vital signs and other evidence of serious illness
5. Assessment of risk for inability to maintain self at home or in community
6. Following legal mandates for those who refuse help or must be hospitalized
7. Obtain history: psychiatric, marital, family, military, past physical or sexual abuse, medication or substance use (including over the counter), physical examination, and laboratory tests
8. If necessary, additional assessments including physical examination with neurological examination, neurobehavioral and/or neurocognitive examination, specialized laboratory tests, or lumbar puncture
9. Mental status examination
10. Assess functional and psychosocial support system
11. Identify emergent psychosocial needs requiring immediate intervention
12. Diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for schizophrenia; schizoaffective; atypical psychosis; rapid cycler; current manic, hypomanic, or mixed episode; current bipolar depressive; cyclothymia; current non bipolar depressive; past history of bipolar disorder; or bipolar disorder
13. Establishing agreement to treatment plan
14. Treatment of patient for cyclothymia, past history of bipolar disorder, and psychotic disorder
15. Psychosocial rehabilitation, as needed
16. Determination of care setting: day hospital, inpatient hospitalization, and assertive case management (ACM)
17. Establishing contact with family members

Treatment

1. Antipsychotic agents - conventional
* Chlorpromazine
* Thioridazine
* Mesoridazine
* Trifluoperazine
* Fluphenazine
* Perphenazine
* Thiothixene
* Loxapine
* Haloperidol
* Molindone
2. Second generation antipsychotic agents
* Clozapine
* Risperidone
* Olanzapine
* Quetiapine
* Ziprasidone
* Aripiprazole
3. Patient and family education
4. Assessment of response in 6 to 8 weeks
5. Changing medication based on treatment response or side effects and reassess at 6 to 8 weeks

Management

1. Assessment of seven domains and initiate psychosocial rehabilitation as needed
2. Assessment of independent living skills (ILS)
3. Referral to ILS training including cognitive behavioral therapy (CBT)
4. Exit counseling and referral for continued training
5. Assessment of housing needs (unsupported housing, residential treatment support, and supported housing) and refer for placement as needed
6. Assessment of level of family support
7. Providing family education and referring to community-based advocacy/assistance programs, as needed
8. Assessment of social skills difficulties and refer for social skills training
9. Providing supported employment (SE) and transitional employment, as needed
10. Assess level of case management needs and implement as needed:
* Standard case management
* Assertive community treatment (ACT)
* Intensive case management (ICM)
* Mental health intensive case management (MHICM)

MAJOR OUTCOMES CONSIDERED

* Efficiency and effectiveness of initial assessment process
* Control of symptoms
* Complications and morbidity rates
* Level of patient and family satisfaction regarding the management of psychosis
* Recovery rates and rates of relapse
* Clinical and social functioning of patient
* Quality of life
* Cost of care
* Need for hospitalization and length of hospital stay
* Compliance with medication