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Nervenheilkunde 2009; 28(07): 448-455
DOI: 10.1055/s-0038-1628659
Update Neurologie
Schattauer GmbH

Leitlinienbasierte Therapie der Schizophrenie

Schizophrenia treatment based on practice guidelines
T. Wobrock
1   Abteilung für Psychiatrie und Psychotherapie, Zentrum Psychosoziale Medizin, Georg-August-Universität Göttingen
,
S. Weinmann
2   Institut für Sozialmedizin, Epidemiologie und Gesundheitsökonomie, Charité Universitätsmedizin Berlin
,
P. Falkai
1   Abteilung für Psychiatrie und Psychotherapie, Zentrum Psychosoziale Medizin, Georg-August-Universität Göttingen
,
W. Gaebel
3   Klinik und Poliklinik für Psychiatrie und Psychotherapie der Heinrich Heine-Universität, Rheinische Kliniken Düsseldorf
› Author Affiliations
Further Information

Publication History

Eingegangen am: 10 November 2008

angenommen am: 12 March 2009

Publication Date:
24 January 2018 (online)

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Zusammenfassung

Die S3-Praxisleitlinie Schizophrenie der Deutschen Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde (DGPPN) beinhaltet systematisch entwickelte und evidenzbasierte Therapieempfehlungen mit dem Ziel, die Entscheidungen von Ärzten und Patienten über eine angemessene Behandlung in spezifischen klinischen Situationen zu unterstützen. Sie dient der Verbesserung der Behandlungsqualität und soll helfen, den Ausgang der Erkrankung günstig zu beeinflussen. Die vorliegende Arbeit beschreibt den Entstehungsprozess der Leitlinie und diskutiert ausgewählte Aspekte der Akut- und Langzeittherapie sowie der Behandlung unter besonderen Bedingungen auch anhand neuer Studienergebnisse. Die Empfehlung des bevorzugten Einsatzes von Antipsychotika der zweiten Generation (Atypika) in der Leitlinie wird mit Hinweisen auf eine überlegene Wirksamkeit auf Negativsymptome, kognitive Störungen, in der Rezidivprophylaxe und einem niedrigeren Risiko für Spätdyskinesien begründet, wobei diesen Vorteilen das bei einigen Atypika erhöhte Risiko von Gewichtszunahme, Diabetes mellitus und anderen metabolischen Störungen entgegensteht. Individuelle Behandlungsbedingungen, früheres gutes Ansprechen und die substanzabhängigen unerwünschten Wirkungen auf Stoffwechsel, Herz-Kreislaufsystem, Blutbild und Hormonstatus sind bei der Auswahl des Antipsychotikums zu berücksichtigen. Neben der Pharmakotherapie sollten phasenabhängig auch psycho- und soziotherapeutische Maßnahmen in den Gesamtbehandlungsplan routinemäßig eingebunden werden.

Summary

The practice guideline on schizophrenia by the German Society of Psychiatry, Psychotherapy and Nervous Diseases (DGPPN) includes systematically developed and evidence-based treatment recommendations that assist clinicians and patients in making decisions about appropriate treatment for specific conditions. The practice guideline intends to improve the quality of care and outcome of schizophrenia. This paper reviews the process of the guideline development and discusses selected aspects of acute and long-term treatment as well as treatment strategies under special conditions with regard to recent published studies. The recommendation of preferential using second generation antipsychotics is based upon hints towards superior efficacy in the improvement of negative symptoms, cognitive dysfunction, relapse prevention and a lower risk of tardive dyskinesia. These advantages have to be balanced against the higher risk of weight gain, elevation of blood glucose and other metabolic side effects of some second generation antipsychotics. Within the selection of the specific antipsychotic agent individual treatment conditions, previous treatment response, and substance-related side effects on metabolism, circulation and blood pressure, blood cell count and hormonal status should be considered. Besides pharmacotherapy, psychological and sociotherapeutic interventions should be included routinely in the treatment plan depending on the individual treatment phase.

Schlüsselwörter

Schizophrenie - evidenzbasierte Medizin - Leitlinienentwicklung - Therapieempfehlungen

Keywords

Schizophrenia - evidence-based medicine - guideline development - treatment recommendation
 

  • Literatur

  • 1 Adams CE. et al. Systematic meta-review of depot antipsychotic drugs for people with schizophrenia. Br J Psychiatry 2001; 179: 290-299.
    CrossrefPubMedGoogle Scholar
  • 2 Allison DB. et al. Antipsychotic-induced weight gain: a comprehensive research synthesis. Am J Psychiatry 1999; 156: 1686-1696.
    PubMedGoogle Scholar
  • 3 Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF). Erarbeitung von Leitlinien für Diagnostik und Therapie. Kriterien für die Qualität von Leitlinien 2004. http://www.awmf-online.de/ oder http://leitlinien.net/
  • 4 Baldessarini RJ, Cohen BM, Teicher MH. Significance of neuroleptic dose ans plasma level in the pharmacological treatment of psychoses. Arch Gen Psychiatry 1988; 45: 79-91.
    CrossrefPubMedGoogle Scholar
  • 5 Bollini P. et al. Antipsychotic drugs: is more worse? a meta-analysis of the published randomized control trials. Psychol Med 1994; 24: 307-316.
    CrossrefPubMedGoogle Scholar
  • 6 Bustillo JR. et al. Differential effect of clozapine on weight: a controlled study. Am J Psychiatry 1996; 153: 817-819.
    CrossrefPubMedGoogle Scholar
  • 7 Caspari D, Wobrock T. Cannabispsychosen – Vom eigenständigen Krankheitsbild zum Komorbiditätsmodell. Sucht 2004; 50 (05) 320-326.
    CrossrefGoogle Scholar
  • 8 Chakos M. et al. Effectiveness of second-generation antipsychotics in patients with treatment-resistant schizophrenia: a review and meta-analysis of randomized trials. Am J Psychiatry 2001; 158 (04) 518-526.
    CrossrefPubMedGoogle Scholar
  • 9 Correll CU. et al. Early prediction of antipsychotic response in schizophrenia. Am J Psychiatry 2003; 160 (11) 2063-2065.
    CrossrefPubMedGoogle Scholar
  • 10 Correll CU, Leucht S, Kane JM. Lower risk for tardive dyskinesia associated with second-generation antipsychotics: a systematic review of 1-year studies. Am J Psychiatry 2004; 161 (03) 414-425.
    CrossrefPubMedGoogle Scholar
  • 11 Deutsche Gesellschaft für Psychiatrie, Psychotherapie und Nervenheilkunde (DGPPN) (Hrsg.). S3-Praxisleitlinien Psychiatrie und Psychotherapie. Band 1. Behandlungsleitlinie Schizophrenie. Leitlinienprojektgruppe. Gaebel W, Falkai P, Weinmann S, Wobrock T. Darmstadt: Steinkopff-Verlag; 2006
  • 12 Dixon LB, Lehman AF, Levine J. Conventional antipsychotic medications for schizophrenia. Schizophr Bull 1995; 21 (04) 567-577.
    CrossrefPubMedGoogle Scholar
  • 13 Falkai P. et al. WFSBP Task Force on Treatment Guidelines for Schizophrenia. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, Part 1: acute treatment of schizophrenia. World J Biol Psychiatry 2005; 06 (03) 132-191.
    CrossrefPubMedGoogle Scholar
  • 14 Gaebel W. et al. First vs multiple episode schizophrenia: two-year outcome of intermittent and maintenance medication strategies. Schizophr Res 2002; 53: 145-159.
    CrossrefPubMedGoogle Scholar
  • 15 Gaebel W. et al. Maintenance treatment with risperidone or low-dose haloperidol in first-episode schizophrenia. One-year results of a randomized controlled trial within the German Research Network on Schizophrenia. J Clin Psychiatry 2007; 68: 1763-1774.
    CrossrefPubMedGoogle Scholar
  • 16 Glassman AH, Bigger Jr JT. Antipsychotic drugs: prolonged QTc interval, torsade de pointes, and sudden death. Am J Psychiatry 2001; 158: 1774-1782.
    CrossrefPubMedGoogle Scholar
  • 17 Harvey PD, Keefe RSE. Studies of cognitive change in patients with schizophrenia following novel antipsychotic treatment. Am J Psychiatry 2001; 158: 176-184.
    CrossrefPubMedGoogle Scholar
  • 18 Jones PB. et al. Randomized controlled trial of the effect on Quality of Life of secondvs first-generation antipsychotic drugs in schizophrenia: Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS 1). Arch Gen Psychiatry 2006; 63 (10) 1079-87.
    CrossrefPubMedGoogle Scholar
  • 19 Kahn RS. et al. Effectiveness of antipsychotic drugs in first-episode schizophrenia and schizophreniform disorder: an open randomised clinical trial. Lancet 2008; 371 9618 1085-97.
    CrossrefPubMedGoogle Scholar
  • 20 Kane JM, Woerner M, Lieberman J. Tardive dyskinesia: prevalence, incidence, and risk factors. J Clin. Psychopharmacol 1988; 08: 52S-56S.
    CrossrefGoogle Scholar
  • 21 Kissling W. Guidelines for neuroleptic relapse prevention. Berlin: Springer Verlag; 1991
    Google Scholar
  • 22 Kohen D. Diabetes mellitus and schizophrenia: historical perspective. Br J Psychiatry 2004; 184 (Suppl. 47) s64-66.
    CrossrefPubMedGoogle Scholar
  • 23 Lehman AF, Steinwachs DM, PORT Co-investigators. Translating research into practice: the Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations. Schizophr Bull 1998; 24: 1-10.
    CrossrefPubMedGoogle Scholar
  • 24 Lehman AF. et al. Practice guideline for the treatment of patients with schizophrenia, second edition. Am J Psychiatry 2004; 161: 1-56.
    CrossrefPubMedGoogle Scholar
  • 25 Leucht S. et al. Relapse prevention in schizophrenia with new generation antipsychotics: a systematic review and exploratory meta-analysis of randomized, controlled trials. Am J Psychiatry 2003; 160: 1209-1222.
    CrossrefPubMedGoogle Scholar
  • 26 Lieberman JA. et al. Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med 2005; 353 (12) 1209-1223.
    CrossrefPubMedGoogle Scholar
  • 27 Lindenmayer JP. et al. Changes in glucose and cholesterol levels in patients with schizophrenia treatedwith typical or atypical antipsychotics. Am J Psychiatry 2003; 160 (02) 290-296.
    CrossrefPubMedGoogle Scholar
  • 28 Lindenmayer JP. et al. A randomized controlled trial of olanzapine versus haloperidol in the treatment of primary negative symptoms and neurocognitive deficits in schizophrenia. J Clin Psychiatry 2007; 68 (03) 368-79.
    CrossrefPubMedGoogle Scholar
  • 29 McGorry et al. Summary Australian and New Zealand clinical practice guideline for the treatment of schizophrenia. Australasian Psychiatry 2003; 11 (02) 136-147.
    CrossrefGoogle Scholar
  • 30 Möller HJ. Management of the negative symptoms of schizophrenia. New treatment options. CNS Drugs 2003; 17 (11) 793-823.
    CrossrefPubMedGoogle Scholar
  • 31 National Institute for Clinical Excellence. Core Interventions in the Treatment of Schizophrenia. NICE, London, 2003. www.nice.org.uk
  • 32 Schooler N. et al. Risperidone and haloperidol in first-episode psychosis: a long-term randomized trial. Am J Psychiatry 2005; 162 (05) 947-953.
    CrossrefPubMedGoogle Scholar
  • 33 Sepehry AA. et al. Selective serotonin reuptake inhibitor (SSRI) add-on therapy for the negative symptoms of schizophrenia: a meta-analysis. J Clin Psychiatry 2007; 68 (04) 604-10.
    CrossrefPubMedGoogle Scholar
  • 34 Stahl SM, Grady MM. A critical review of atypical antipsychotic utilization: comparing monotherapy with polypharmacy and augmentation. Curr Med Chem 2004; 11 (03) 313-27.
    CrossrefPubMedGoogle Scholar
  • 35 Tarrier N. et al. Durability of the effects of cognitivebehavioural therapy in the treatment of chronic schizophrenia: 12-month follow-up. Br J Psychiatry 1999; 174: 500-504.
    CrossrefPubMedGoogle Scholar
  • 36 Waraich PS. et al. Haloperidol dose for the acute phase of schizophrenia (Cochrane Review). In: The Cochrane Library, Issue 2. Chichester, UK: John Wiley & Sons, Ltd; 2004
    Google Scholar
  • 37 Wobrock T, Falkai P. Leitliniengestützte Therapie schizophrener Psychosen. INFO Neurologie & Psychiatrie 2003; 05: 34-45.
    Google Scholar
  • 38 Wobrock T. et al. Schizophrenie und Sucht. Psycho-Neuro 2005; 31 (09) 433-440.
    Article in Thieme ConnectGoogle Scholar
  • 39 Wobrock T, Soyka M. Pharmacotherapy of schizophrenia with comorbid substance use disorder – Reviewing the evidence and clinical recommendations. Prog Neuropsychopharmacol Biol Psychiatry 2008; 32 (06) 1375-1385.
    CrossrefPubMedGoogle Scholar
  • 40 Wobrock T, Falkai P. Kombinationstherapie schizophren Erkrankter jenseits der Polypharmazie. J Neurol Neurochirg Psychiatr 2008; 09: 32-38.
    Google Scholar