What are the treatment guidelines for schizophrenia according to IPS (Indian Psychiatric Society) guidelines?

Treatment Guidelines for Schizophrenia According to IPS Guidelines

Note: The provided evidence contains American Psychiatric Association (APA) guidelines from 2020, not Indian Psychiatric Society (IPS) guidelines. The following recommendations are based on the available APA evidence, which represents the most current and comprehensive guideline-level evidence for schizophrenia treatment.

Initial Assessment and Treatment Planning

All patients with schizophrenia require a comprehensive initial psychiatric evaluation that includes assessment of psychiatric symptoms, trauma history, substance use (particularly tobacco), physical health status, psychosocial and cultural factors, cognitive function, and suicide/aggression risk. 1

• Use quantitative measures to identify symptom severity and functional impairments at baseline 1
• Document a comprehensive, person-centered treatment plan that integrates both pharmacological and nonpharmacological evidence-based interventions 1

Pharmacological Treatment

First-Line Antipsychotic Treatment

Initiate antipsychotic monotherapy immediately for all patients with schizophrenia, selecting the medication collaboratively with the patient based on side-effect profiles, efficacy, and patient preference. 1

• Start at therapeutic dose and maintain for minimum 4 weeks before declaring treatment failure, assuming confirmed adherence 2, 3
• Monitor continuously for effectiveness and side effects throughout treatment 1
• Continue the same antipsychotic medication indefinitely if symptoms improve, as maintenance treatment reduces relapse risk. 1

Treatment-Resistant Schizophrenia

Switch to clozapine after two failed trials of different antipsychotics (each at therapeutic dose for 4 weeks minimum). 1, 3

• Clozapine is the only evidence-based treatment for treatment-resistant schizophrenia (1B recommendation) 1
• Offer metformin concomitantly with clozapine to attenuate weight gain 2, 3
• Do not delay clozapine initiation once treatment resistance is established 3

Special Indications for Clozapine

Use clozapine when suicide risk remains substantial despite other treatments (1B recommendation). 1

• Consider clozapine when aggressive behavior remains substantial despite other treatments (2C suggestion) 1

Long-Acting Injectable Antipsychotics

Offer long-acting injectable antipsychotic formulations to patients who prefer this route or have documented poor/uncertain adherence history. 1

• Long-acting injectables ensure therapeutic drug levels and confirm adherence 3

Management of Antipsychotic Side Effects

Extrapyramidal Symptoms

Treat acute dystonia with anticholinergic medication immediately (1C recommendation). 1

For parkinsonism, implement one of these strategies: 1

• Lower the antipsychotic dose
• Switch to another antipsychotic with lower EPS risk
• Add anticholinergic medication

For akathisia, use one of these approaches: 1

• Lower the antipsychotic dose
• Switch to another antipsychotic
• Add benzodiazepine
• Add beta-adrenergic blocking agent

Tardive Dyskinesia

Treat moderate to severe or disabling tardive dyskinesia with a reversible VMAT2 inhibitor (1B recommendation). 1

Psychosocial Interventions

First-Episode Psychosis

Enroll all patients experiencing first-episode psychosis in a coordinated specialty care program (1B recommendation). 1

Core Psychosocial Treatments (All 1B Recommendations)

Provide cognitive-behavioral therapy for psychosis (CBTp) to all patients with schizophrenia. 1

Deliver psychoeducation to all patients with schizophrenia. 1

Offer supported employment services to all patients with schizophrenia. 1

Provide assertive community treatment for patients with poor engagement history leading to frequent relapse, homelessness, legal difficulties, or imprisonment. 1

Additional Psychosocial Interventions (2B-2C Suggestions)

• Offer family interventions to patients with ongoing family contact 1
• Provide interventions aimed at developing self-management skills and enhancing person-oriented recovery 1
• Consider cognitive remediation 1
• Offer social skills training when enhanced social functioning is a therapeutic goal 1
• Consider supportive psychotherapy 1

Critical Monitoring Parameters

Monitor metabolic parameters proactively, as metabolic side effects represent a major cause of morbidity and mortality in schizophrenia. 3

• Assess weight, blood pressure, fasting glucose, and lipid profile at baseline and regularly during treatment 3
• Monitor for extrapyramidal symptoms, orthostatic hypotension, and sedation 3
• Use standardized scales to assess psychotic symptom severity 3

Common Pitfalls to Avoid

Do not switch antipsychotics before completing a minimum 4-week trial at therapeutic dose with confirmed adherence. 4, 3

Do not use antipsychotic polypharmacy except after optimizing monotherapy and trying clozapine, as polypharmacy causes more side effects without additional benefit. 3

Do not ignore physical health monitoring—obesity, diabetes, hyperlipidemia, and cardiovascular disease contribute significantly to the 15-20 year reduced life expectancy in schizophrenia. 1