TYPICALS OR ATYPICALS? ..... DO WE HAVE A SAY?
December was the month that saw the publication of the NICE (National Institute of Clinical Excellence) (http://www. nice.org) Clinical Guidelines for the Treatment of Schizophrenia.
NICE was founded in 1999 as part of the NHS to implement evidence based clinical practice and provide uniform guidelines for treatment in England and Wales. The main reason for this was to uniform treatment across the country and to let practice be guided by the "best possible" evidence.
For some time there has been a debate within the National Health Service on the treatment of schizophrenia, mainly the pharmacological aspects. This has focused on the use of typical antipsychotics (Haloperidol and others) compared to atypical antipsychotics ( Olanzapine, Risperidone, etc.).
In 1999 the Clinical Guidelines published by the Royal College of Psychiatrists recommended the use of typical antipsychotics as first line treatment strategy in schizophrenia. This was based on clinical trials where atypicals had been shown to be better compared to only high doses of typical antipsychotics, and also to the higher cost of atypicals.
There are widely divisive opinions and widely differing practices in the use of new antipsychotics. In the States these are used more commonly than typicals. In the UK atypical antipsychotics are much less used and they are often used together with typical neuroleptics.
A huge difference exists between different trusts, mostly due to the cost of atypical antipsychotics.
NICE guidelines make several recommendations for the treatment of acute and chronic schizophrenia in general and specialist care settings. Underlined are elements of care that are judged as best practice for health professionals involved in treating patients with schizophrenia, after a review of the best available evidence by a group of sufferers and clinicians in the field of mental health.
The need to establish a "collaborative working relationship with patients and their carers and to offer them help, treatment and support in an atmosphere of optimism and hope" is considered fundamental. The guidelines emphasize also the need of a collaborative decision and informed consent on treatment between doctor and patient.
The nature of the illness and the difficulties for sufferers in being able to make an informed decision is taken into account in the guidelines, and clinicians are advised to make every effort to allow patients to give consent and understand the nature of the treatment being given, before this is commenced.
Very relevant is also the information given to carers and families of sufferers.
Regarding oral atypical antipsychotics, their use in moderate doses is recommended in newly diagnosed cases of schizophrenia as first line treatment. The use of one antipsychotic in moderate doses at any one time is recommended. It seems in fact that almost half of the patients treated with antipsychotics receive more than one antipsychotic, and evidence shows that this does not increase clinical efficacy.
Interventions aimed at supporting the family and psychological interventions, mainly in the form of cognitive-behavioural therapy are indicated as an indispensable part of the treatment of schizophrenia.
Its clearly early to say what the impact of the guidelines will be on clinical practice in the UK, but surely the debate will continue to be hot around which treatment should be the one of choice in schizophrenia. It will also be very interesting to see how different trusts in the country will implement the guidelines.