The Texas Medication Algorithm Project Antipsychotic Algorithm for Schizophrenia: 2006 Update

Troy A. Moore, Pharm.D., M.S.; Robert W. Buchanan, M.D.; Peter F. Buckley, M.D.; John A. Chiles, M.D.; Robert R. Conley, M.D.; M. Lynn Crismon, Pharm.D.; Susan M. Essock, Ph.D.; Molly Finnerty, M.D.; Stephen R. Marder, M.D.; Del D. Miller, Pharm.D., M.D.; Joseph P. McEvoy, M.D.; Delbert G. Robinson, M.D.; Nina R. Schooler, Ph.D.; Steven P. Shon, M.D.; T. Scott Stroup, M.D., M.P.H.; and Alexander L. Miller, M.D.

Background: A panel of academic psychiatrists and pharmacists, clinicians from the Texas public mental health system, advocates, and consumers met in June 2006 in Dallas, Tex., to review recent evidence in the pharmacologic treatment of schizophrenia. The goal of the consensus conference was to update and revise the Texas Medication Algorithm Project (TMAP) algorithm for schizophrenia used in the Texas Implementation of Medication Algorithms, a statewide quality assurance program for treatment of major psychiatric illness.

Method: Four questions were identified via premeeting teleconferences. (1) Should antipsychotic treatment of first-episode schizophrenia be different from that of multiepisode schizophrenia? (2) In which algorithm stages should first-generation antipsychotics (FGAs) be an option? (3) How many antipsychotic trials should precede a clozapine trial? (4) What is the status of augmentation strategies for clozapine? Subgroups reviewed the evidence in each area and presented their findings at the conference.

Results: The algorithm was updated to incorporate the following recommendations. (1) Persons with first-episode schizophrenia typically require lower antipsychotic doses and are more sensitive to side effects such as weight gain and extrapyramidal symptoms (group consensus). Second-generation antipsychotics (SGAs) are preferred for treatment of first-episode schizophrenia (majority opinion). (2) FGAs should be included in algorithm stages after first episode that include SGAs other than clozapine as options (group consensus). (3) The recommended number of trials of other antipsychotics that should precede a clozapine trial is 2, but earlier use of clozapine should be considered in the presence of persistent problems such as suicidality, comorbid violence, and substance abuse (group consensus). (4) Augmentation is reasonable for persons with inadequate response to clozapine, but published results on augmenting agents have not identified replicable positive results (group consensus).

Conclusions: These recommendations are meant to provide a framework for clinical decision making, not to replace clinical judgment. As with any algorithm, treatment practices will evolve beyond the recommendations of this consensus conference as new evidence and additional medications become available.

(J Clin Psychiatry 2007;68:1751-1762)

Received April 30, 2007; accepted Aug. 28, 2007. From the Department of Psychiatry, The University of Texas Health Science Center at San Antonio (Drs. Moore and A. L. Miller); Maryland Psychiatric Research Center, University of Maryland School of Medicine, Baltimore (Drs. Buchanan and Conley); the Department of Psychiatry, Medical College of Georgia, Augusta (Dr. Buckley); the Department of Psychiatry, University of Washington School of Medicine, Seattle (Dr. Chiles); College of Pharmacy, The University of Texas at Austin (Dr. Crismon); the Department of Mental Health Services and Policy Research, New York State Psychiatric Institute, New York (Dr. Essock); New York Office of State Mental Health, N.Y. (Dr. Finnerty); West Los Angeles VA Health Care Center, Calif. (Dr. Marder); the Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City (Dr. D. D. Miller); the Department of Psychiatry and Behavioral Sciences, Duke University, Durham, N.C. (Dr. McEvoy); the Department of Psychiatry, The Zucker Hillside Hospital of the North Shore-Long Island Jewish Health System, Glen Oaks, N.Y., Feinstein Institute for Medical Research, Manhasset, N.Y., and the Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Bronx, N.Y. (Dr. Robinson); the Department of Psychiatry, Georgetown University School of Medicine, and VISN5 MIRECC, Department of Veterans Affairs, Washington, D.C. (Dr. Schooler); the Texas Department of State Health Services, Austin (Dr. Shon); and the Department of Psychiatry, University of North Carolina at Chapel Hill (Dr. Stroup).

Funding for this conference was provided by the Texas Department of State Health Services, Austin. No funding for the conference was sought from or provided by pharmaceutical companies. The conference proceedings were closed and confidential. No industry representatives were present at the conference or included in decision making.

Acknowledgments appear at the end of this article.

Financial disclosure appears at the end of this article.

Corresponding author and reprints: Troy A. Moore, Pharm.D., M.S., Department of Psychiatry, The University of Texas Health Science Center at San Antonio, San Antonio, TX (e-mail: mooret3@uthscsa.edu).