Here you will find a disease management system and a "virtual consultant" for the pharmacotherapy of schizophrenia, schizoaffective disorder, and schizophreniform psychosis.
The User Tips section provides some pointers about the mechanics of using this program. Caution: In the program, you will find flowcharts of the question-and-answer sequences in this program. These look like simple algorithms and you may be tempted to try to quickly find the system's recommendations by scanning these flowcharts. Do not do this, unless you are already an experienced user. You will miss many of the important nuances in the logic and alternatives to consider as you progress systematically through the questions that are asked to narrow down the specific issues with your patient.
The algorithm reflects the author's analysis of published research as well as clinical experience of experts and experienced clinicians, as expressed formally, informally, on the Internet, and in various practice guidelines and consensus statements.
Earlier versions of parts of the algorithm appeared in The Neuroleptic Resistant Psychosis Psychopharmacology Consultant, a DOS program published by Mental Health Connections, Inc. 1991-1995. (Editions 1.0 through 4.0) The most recent written summary of the contents of this program is: Osser DN, Zarate CAJr. Consultant for the pharmacotherapy of schizoprenia. Psychiatric Annals 1999;29(5):252-267.
The use of this algorithm is predicated upon the clinician making a criteria-based DSM-4 diagnosis. Since this is an evidence-based as well as consensus-informed algorithm, it is important to note that almost all the published research studies in modern psychopharmacology (over the past 15 years) utilize DSM criteria as the basis for entering patients into the studies. Hence, if the clinician uses more vague or alternative criteria, this may reduce the validity of the recommendations to be found in this algorithm. A central premise of the approach to treatment outlined in this program is the primary importance of treating diagnoses, not symptoms. The vast majority of the evidence basis for psychopharmacology practice comprises information about treating patients with particular diagnoses, not symptoms independent of diagnosis. Many treatment errors arise from treating symptoms without identifying their cause. It appears to be one of the primary causes of polypharmacy and resultant toxicity from drug interactions and compounded side effects.
This algorithm is designed to guide the use of pharmacologic treatments. It assumes that several important ingredients in successful treatment have been addressed:
Many of the questions and recommendations have a clinical confidence rating icon in their windows. These give an indication of the scientific strength of data supporting the use of the recommendations and distinctions made by the questions. Confidence ratings have three levels:
Your feedback and your clinical experience are most valuable to help us refine this algorithm.
The "Feedback" button takes you to our automatic system for sending observations to us. Recent feedback of interest to users is posted regularly in the "Users Comments" section.
Our addresses are:
Dr. David N. Osser
% Mental Health Connections, Inc.
21 Blossom St.
Lexington, MA 02173
E-mail: dno@world.std.com
This program is designed to supplement and enhance the expertise of the psychiatrist. However, management of any individual patient is the responsibility of the prescribing physician. Recommendations from this program should only be used in the context of your overall knowledge of the patient.
End of Introduction.
Mary muses over medications, 1997
Painted by Carolyn Crocker, used by permission.
Here are listed updates and additions to this program. They are listed by date, with the most recent first.
April 15, 2003. Extensively revised section on Neuroleptic Malignant Syndrome, by Ronald Gurrera, M.D. of Harvard Medical School. Cleck here to see it. There is also information on dosing the new antipsychotic, aripiprazole (Abilify). Click here to see that. We are still thinking about the placement of aripiprazole in the overall algorithm.
March 21, 2002. Corrected logic flow error. If patient with unsatisfactory response is currently on a typical neuroleptic, consultant now asks if there has been a previous adequate trial of the same or similar neuroleptic. If there has been, the consultant will not question you about the adequacy of the trial of the present neuroleptic but will proceed immediately to ask about use of atypical (second generation) antipsychotics. See the new logic in the flowchart here.
February 25, 2002. Added new table of comparative side effects of antipsychotics in the drop-up menu that can be accessed at any time in the algorithm. Go here to see it.
January 11, 2002. Improvement in section on assessment and management of breakthrough symptoms in patients who were complying with antipsychotic medication. Go here to see it.
November 15, 2001. New section on Tardive Dyskinesia, update to section on Neuroleptic Malignant Syndrome. In a new feature, we now address directly the problem of what to do with patients with an unsatisfactory level of recovery, who are on two or more antipsychotics at the time of consultation. Go here to explore the new material.
September 1, 2001. Much new material on the selection of atypical antipsychotics considering their optimal dosing, rapidity of response, and their side effects. Information about ziprasidone has been added at several points, although the full delineation of the role of ziprasidone in all nodes of the algorithm is incomplete pending accumulation of further information about the optimal role of this new antipsychotic. There is also a much expanded section on treatment of agitated patients requiring parenteral medication.
April 20, 2001. Ziprasidone has been introduced into the algorithm as a potential first and second line option for schizophrenia. There was also a general updating and refinement of the text for accuracy at various points, brought about by a thoughtful review by Jack Rosenblatt, M.D., editor of Currents in Affective Disorders. We thank him for his many helpful suggestions.
November 9, 2000. Updates on some of the sections on treatment resistant patients, augmentation strategies for people who have failed at least two sequential antipsychotic monotherapy trials, and steps to take to optimize and augment response to clozapine.
October 6, 2000. All places in the program where thioridazine (Mellaril) or mesoridazine (Serentil) are mentioned are updated with information about the new boxed warnings about QTc interval prolongation risks. These drugs have been "downgraded" in priority, in accordance with the new FDA-required package insert statements that they are to be used only after failure on other antipsychotics and only when there is monitoring for QTc and avoidance of certain drug interactions.
February 14, 2000 Updated the link to PubMed's new site. Further refinements of the treatment trial reporting process.
November 4, 1999 Many refinements of the drug trial reporting process have been made. Clinician and patient versions of a Patient Functioning Questionnaire have been added.
October 14, 1999 A few changes in the text.
October 3, 1999 The drug trial reporting form has been improved and recommendations have been numbered so the user can easily identify the appropriate recommendation for reporting.
December 1, 1998 The Table "Levels of Recovery from Psychotic Disorders" was added. It is referred to in several places in the program. It can be printed for easy access when not at the computer. Small changes in the algorithm were added.
September 18, 1998: Program essentially complete in its new version.
