Last updated May 12, 2023

Management of First-Episode Psychosis and Schizophrenia

Assessment and Evaluation of Suspected Psychosis

or individuals with suspected psychosis, we suggest using evidence-based screening tools in specialty mental health settings to differentiate/identify individuals at risk for transition to psychosis. (Weak)
315994

For individuals with suspected psychosis, there is insufficient evidence to recommend for or against biomarker screening tools (e.g., magnetic resonance imaging–based prediction system, serum biomarker panels) to differentiate/identify individuals at risk for transition to psychosis. (Neither for or Against)
315994

First-episode Psychosis

We recommend treatment/management with early intervention services for individuals with first-episode psychosis. (Strong)
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We recommend the use of family interventions (including problem solving–based self-learning, education, and mutual family support) for individuals with first-episode psychosis. (Strong)
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We suggest the use of the Individual Placement and Support model of supported employment for individuals with first-episode psychosis with a goal of employment and/or education. (Weak)
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There is insufficient evidence to recommend for or against any specific duration for participation in specialized early intervention services for individuals with first-episode psychosis. (Neither for or Against)
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There is insufficient evidence to recommend for or against a specific duration for treatment with antipsychotic medication after response or remission for individuals with first-episode psychosis. (Neither for or Against)
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Pharmacologic Interventions for Psychosis

We recommend the use of an antipsychotic medication other than clozapine for the treatment of an acute episode in individuals with schizophrenia or first-episode psychosis who have previously responded to antipsychotic medications. The choice of antipsychotic medication should be based on an individualized evaluation that considers patient characteristics and side effect profiles of the different antipsychotic medications. (Strong)
315994

We recommend the use of an antipsychotic medication for the maintenance treatment of schizophrenia to prevent relapse and hospitalization in individuals with schizophrenia who have responded to treatment. Choice of antipsychotic medication should be based on an individualized evaluation that considers patientspecific characteristics and side effect profiles of the different antipsychotic medications. ()
315994

We suggest a trial of another antipsychotic medication for individuals with schizophrenia who do not respond to (or tolerate) an adequate trial of an antipsychotic medication. Choice of antipsychotic medication should be based on an individualized evaluation that considers patient-specific characteristics and side effect profiles of the different antipsychotic medications. (Weak)
315994

We suggest offering long-acting injectable antipsychotics to improve medication adherence in individuals with schizophrenia. (Weak)
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We recommend the use of clozapine for individuals with treatmentresistant schizophrenia. (Strong)
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We suggest augmenting clozapine with another second-generation antipsychotic medication for individuals with treatment-resistant schizophrenia who have not experienced an adequate response to clozapine. (Weak)
315994

Pharmacologic Interventions for Treatment of Side Effects

There is insufficient evidence to recommend for or against any treatment for hyperprolactinemia-related side effects of antipsychotic medications in individuals with schizophrenia. (Neither for nor Against)
315994

We suggest using metformin, topiramate, or aripiprazole augmentation for treatment of metabolic side effects of antipsychotic medication and weight loss for individuals with schizophrenia (Weak)
315994

We suggest a trial of a vesicular monoamine transporter 2 inhibitor for the treatment of tardive dyskinesia for individuals with schizophrenia and tardive dyskinesia (Weak)
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We suggest a trial of diphenhydramine for individuals with schizophrenia who are experiencing sialorrhea as a side effect of clozapine. (Weak)
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There is insufficient evidence to recommend for or against augmentation with any non-antipsychotic medication for treatment of cognitive and/or negative symptoms for individuals with schizophrenia. (Neither for nor Against)
315994

Non-pharmacologic Interventions

We recommend the use of psychosocial interventions provided to a primary support person or family member to decrease the risk of relapse and hospitalization for individuals with schizophrenia. (Strong)
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We recommend the use of service models based on standard Assertive Community Treatment in individuals with schizophrenia evidencing severe functional impairments and/or risk for repeated hospitalizations. (Strong)
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We recommend the use of the Individual Placement and Support model of supported employment for individuals with schizophrenia with a goal of employment (Strong)
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There is insufficient evidence to recommend any specific supported housing intervention over another for individuals with schizophrenia experiencing housing insecurity. (Neither for nor Against)
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We suggest compensatory cognitive training programs for the treatment of cognitive impairment for individuals with schizophrenia. (Weak)
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We suggest offering skills training for individuals with schizophrenia evidencing severe and persistent functional impairments and/or deficits in social, social-cognitive, and problem-solving skills. (Weak)
315994

There is insufficient evidence to recommend for or against transcranial direct current stimulation and repetitive transcranial magnetic stimulation for individuals with schizophrenia. (Neither for nor Against)
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There is insufficient evidence to recommend for or against electroconvulsive therapy for individuals with schizophrenia. (Neither for nor Against)
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There is insufficient evidence to recommend for or against the use of motivational interviewing or shared decision making to improve medication adherence for individuals with schizophrenia (Neither for nor Against)
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There is insufficient evidence to recommend for or against the use of the Clubhouse model for vocational rehabilitation to increase employment outcomes for individuals with schizophrenia. (Neither for nor Against)
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There is insufficient evidence to recommend for or against the use of targeted peer-provided interventions for individuals with schizophrenia. (Neither for nor Against)
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We suggest adding aerobic exercise to treatment as usual to reduce symptoms and improve functioning for individuals with schizophrenia (Weak)
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We suggest offering yoga as an adjunct to other evidence-based treatments for positive and negative symptoms for individuals with schizophrenia. (Weak)
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We suggest cognitive behavioral therapy for psychosis in combination with pharmacotherapy for individuals with prodromal and early psychosis. (Weak)
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We suggest the following psychotherapies and psychotherapeutic interventions in combination with pharmacotherapy for individuals with schizophrenia: ·
  • Cognitive behavioral therapy or cognitive behavioral therapy for psychosis, ·
  • Acceptance and mindfulness-based therapies, ·
  • Metacognitive therapy, or
  • Positive psychology interventions.
(Weak)
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There is insufficient evidence to recommend for or against Illness Management and Recovery in combination with pharmacotherapy for individuals with schizophrenia. (Neither for nor Against)
315994

There is insufficient evidence to recommend for or against virtual reality interventions, including avatar therapy, for individuals with schizophrenia. (Neither for nor Against)
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We suggest using telephone-based care management to reduce rehospitalization days for individuals with schizophrenia. (Weak)
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There is insufficient evidence to recommend for or against augmenting pharmacotherapy with acupuncture to reduce negative and positive symptoms for individuals with schizophrenia. (Neither for nor Against)
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There is insufficient evidence to suggest case management to improve preventive screening and/or medical outcomes for individuals with schizophrenia. (Neither for nor Against)
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We recommend a face-to-face individualized smoking cessation intervention tailored specifically to the patient for individuals with schizophrenia. (Strong)
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Management of Co-occurring Conditions

We suggest the use of dietary interventions, exercise, individual lifestyle counseling, and/or psychoeducation for metabolic side effects of antipsychotic medication as well as the delivery of weight management services that are based on a chronic care model (e.g., Enhancing Quality of Care in Psychosis) for individuals with schizophrenia. (Weak)
315994

There is insufficient evidence to recommend specific, integrated, non-integrated, or psychosocial treatments in addition to usual care for individuals with schizophrenia and comorbid substance use disorder. (Neither for nor Against)
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Algorithms

Module A: Primary Care Evaluation and Management of Suspected Psychosis or Possible Schizophrenia


Module B:  Evaluation and Management of First-Episode Psychosis and Schizophrenia by Mental Health Providers


Module C:  Pharmacotherapy for Treatment of First-Episode Psychosis and Schizophrenia

Module C Part 2 - Pharmacotherapy for Treatment of First-Episode Psychosis and Schizophrenia


Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Management of First-Episode Psychosis and Schizophrenia (SCZ)

Authoring Organization

Publication Month/Year

May 11, 2023

Document Type

Guideline

Country of Publication

US

Target Patient Population

Adults with schizophrenia, schizophrenia spectrum disorders, schizoaffective disorder, schizophreniform disorder, or FEP being treated in any setting

Target Provider Population

VA and DoD providers to care for patients with schizophrenia, including primary care providers (PCP), mental health providers, and others involved in the health care team

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant, psychologist

Scope

Counseling, Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D012559 - Schizophrenia, D011609 - Psychosine

Keywords

psychosis, schizophrenia, veterans, VA

Source Citation

VA/DoD Clinical Practice Guideline. (2023). Management of First-Episode Psychosis and Schizophrenia Work Group. Washington, DC: U.S. Government Printing Office.