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Implementation of a Schizophrenia Practice Guideline: Clinical Results

Stefan Weinmann, M.D., Dr.P.H.; Susanne Hoerger; Monika Erath; Reinhold Kilian, Dr.P.H.; Wolfgang Gaebel, M.D.; and Thomas Becker, M.D.

Background: In mental health care, a range of guidelines with sound methodology is available; however, implementation studies in routine care are scarce.

Method: In a controlled before-and-after study design, the pharmacologic part of the German evidence-based schizophrenia guideline was implemented using a quality-circle-based intensive implementation program. 151 adult inpatients with a diagnosis of schizophrenia or schizoaffective disorder (according to ICD-10 criteria) were assessed in 4 psychiatric wards before (N = 77) and after (N = 74) guideline implementation. Treatment process and patient outcome were assessed at admission and discharge using the Positive and Negative Syndrome Scale (PANSS) and predefined process measures. A propensity score model adjusted for baseline psychopathology and sociodemographic variables was used. Data were collected from April to September of 2005 and from January to May of 2006 for the preintervention and postintervention periods, respectively.

Results: After guideline implementation, the rate of antipsychotic monotherapy at discharge increased from 39.5% to 67.6% (p = .021) and the incidence of significant neurologic side effects decreased from 26.3% to 7.0% (p = .038). Antipsychotic dosage and prescriptions of other psychotropic drugs did not change. Although patients in the postintervention group were more severely disturbed at baseline, the reduction in PANSS total score was significantly greater among this group than among the preintervention group (p = .048).

Conclusion: After guideline implementation, we observed significantly more antipsychotic monotherapy and a decrease in adverse drug effects. Changing physician behavior and improving process and outcome measures requires intense efforts.

(J Clin Psychiatry 2008;69:1299-1306. Online Ahead of Print July 15, 2008.)

Received Nov. 4, 2007; accepted Apr. 15, 2008. From the Department of Psychiatry and Psychotherapy II, University of Ulm, Ulm (Drs. Weinmann, Kilian, and Becker and Mss. Hoerger and Erath) and Department of Psychiatry, Heinrich Heine University, Dusseldorf (Dr. Gaebel), Germany.

This research was funded by the University of Ulm within a young investigator programme (grant P.873 to Dr. Weinmann).

Drs. Weinmann and Gaebel have been involved in the development of the German Schizophrenia Guideline. The guideline development and implementation process was not supported by pharmaceutical companies or health authorities.

The authors thank all patients and inpatient staff involved in the guideline implementation study.

Dr. Weinmann has received honoraria from AstraZeneca. Dr. Becker has received grant/research support from AstraZeneca. Drs. Kilian and Gaebel and Mss. Hoerger and Erath report no financial affiliations or other relationships relevant to the subject of this article.

Corresponding author and reprints: Stefan Weinmann, M.D., Department of Psychiatry and Psychotherapy II, University of Ulm, Ludwig-Heilmeyer-Str 2, D-89312 Guenzburg, Germany (e-mail: