Clinical Practice Guidelines Singapore Med J 2011; 52(7) : 521

CME Article
Ministry of Health Clinical Practice
Guidelines: Schizophrenia
Verma S, Chan L L, Chee K S, Chen H, Chin S A, Chong S A, Chua W, Fones C, Fung D,
Khoo C L, Kwek S K D, Ling J, Poh P, Sim K, Tan B L, Tan C, Tan C H, Tan L L, Tay W K

ABSTRACT a diminution or loss of normal emotional and

The Ministry of Health (MOH) has updated the psychological functions. These include affective
clinical practice guidelines on Schizophrenia to flattening (difficulty in expressing emotions),
provide doctors and patients in Singapore with alogia (limited speech with consequent difficulty
evidence-based treatment for schizophrenia. in maintaining a continuous conversation or saying
This article reproduces the introduction and anything new), avolition (extreme apathy with lack of
executive summary (with recommendations initiation, drive and energy, which result in academic,
from the guidelines) from the MOH clinical vocational and social deterioration), anhedonia (lack
practice guidelines on Schizophrenia, for the of pleasure or interest in life) and asociality (social
information of readers of the Singapore Medical withdrawal and few social contacts). Negative
Journal. Chapters and page numbers mentioned symptoms are less obvious and often persist even after
in the reproduced extract refer to the full text the resolution of positive symptoms.
of the guidelines, which are available from the • Cognitive symptoms include impairment in attention,
Ministry of Health website: http://www.moh.gov. reasoning and judgement, and difficulty in processing
sg/mohcorp/publications.aspx?id =26138. The information.
recommendations should be used with reference • Disorganised symptoms refer to disturbances in
to the full text of the guidelines. Following this thinking, speech, behaviour and incongruous affect.
article are multiple choice questions based on the These psychological and behavioural disturbances
full text of the guidelines. are associated with a variety of impairments in
Singapore Med J 2011; 52(7): 521-526 occupational or social functioning. Although there
can be marked deterioration with impairments in
INTRODUCTION multiple domains of functioning (e.g. learning, self-
1.1 An overview of schizophrenia care, working, interpersonal relationships, and living
Ang Mo Kio Clinical features skills), the manifestation of the disorder can vary across
Polyclinic
Changi General Schizophrenia is a mental illness characterised by a persons and within persons over time. Individuals with
Hospital
Community multiplicity of symptoms affecting the fundamental human schizophrenia may also experience symptoms of other
attributes: cognition, emotion and perception. The early age mental disorders, including depression, obsessive and
Wellness Centre
Fones Clinic-
Psychological of onset, varying degree of intellectual and psychosocial compulsive symptoms, somatic concerns, and other
Medicine
Institute of impairment and possibility of long-term disability makes mood or anxiety symptoms.
Mental Health
KK Women’s & schizophrenia one of the most severe and devastating
Children’s Hospital mental illnesses. People with schizophrenia also suffer Aetiology of schizophrenia
Ministry of Health
National University disproportionately from an increased incidence of general Schizophrenia is a complex disorder and arises from a
Hospital
Silver Ribbon medical illness and increased mortality, especially from combination of risk factors, including genetic vulnerability.
(Singapore)
Tan Tock Seng
suicide, which occurs in up to 10% of patients. Although more than 80% of patients with schizophrenia
Hospital No single symptom is pathognomonic of have parents who do not have the disorder, the risk of
(Institutions listed in
alphabetical order) schizophrenia. Symptoms of schizophrenia are divided having schizophrenia is greater in persons whose parents
MOH Clinical into four categories: positive, negative, disorganised and have the disorder; the lifetime risk is 13% for a child with
Practice Guidelines cognitive symptoms. Various combinations of severity in one parent with schizophrenia, 35%–40% for a child with
Workgroup on
Schizophrenia these four categories are found in patients. two affected parents and about 50% concordance rate
Correspondence to: • Positive symptoms are those that appear to reflect the among monozygotic twins. The genetic vulnerability arises
A/Prof Swapna Verma
Tel: (65) 6389 2089
presence of mental features that should not normally be from a complex combination of multiple genes of small
Fax: (65) 6389 2879 present. These include delusions and hallucinations. effect. Environmental risk factors are also necessary and
Email: swapna_
[email protected] • Negative symptoms are those that appear to reflect some operate early in life.
 Singapore Med J 2011; 52(7) : 522

Natural history and course Further, as the rate of physical illnesses like cardiovascular
The peak incidence of schizophrenia is at 21 years. The diseases, obesity and diabetes mellitus are higher among
onset is earlier for men (between ages 15 and 25 years) and patients with schizophrenia as compared to the general
later in women (between ages 25 and 35 years). Childhood population, family physicians would be able to screen and
onset schizophrenia is rare, and psychotic symptoms in this treat these illnesses.
age group may not always be indicative of schizophrenia.
The first psychotic episode is often preceded by a 1.2 Objectives
prodromal phrase. This phase involves a change from This guideline is an update of an earlier guideline on
premorbid functioning and extends up to the time of schizophrenia published by the Ministry of Health,
the onset of frank psychotic symptoms. It may last for Singapore in 2003. These guidelines are developed to
weeks or even years. During the prodromal phase, the provide information to clinicians on the evidenced-based
person experiences substantial functional impairment treatment for schizophrenia.
and nonspecific symptoms such as sleep disturbance,
anxiety, irritability, depressed mood, poor concentration, 1.3 Scope of this guideline
fatigue, and behavioural deficits such as deterioration This guideline covers the treatment of schizophrenia in
in role functioning and social withdrawal. Perceptual the general adult population. These guidelines do not
abnormalities and suspiciousness may emerge later in the cover management of other psychotic disorders like
prodromal phase. Brief Psychotic Disorders, Schizoaffective Disorders,
The psychotic phase progresses through an acute Bipolar Disorders with psychotic symptoms or Delusional
phase, a recovery or stabilisation phase and a stable phase. Disorders. This guideline provides recommendations
The acute phase refers to the presence of florid psychotic for the treatment of acute symptoms, maintenance
features such as delusions, hallucinations, formal thought pharmacotherapy, treatment-resistant schizophrenia,
disorder, and disorganised thinking. The stabilisation adjunctive medication, psychosocial interventions and
(recovery) phase refers to a period after acute treatment. schizophrenia during pregnancy. Cost-effectiveness issues
During the stable phase, negative and residual positive are also considered in this guideline.
symptoms that may be present are relatively consistent
in magnitude and usually less severe than in the acute 1.4 Who this guideline is for
phase. Some patients may be asymptomatic whereas This guideline is intended primarily for all doctors and
others experience nonpsychotic symptoms such as tension, allied healthcare professionals treating patients with
anxiety, depression or insomnia. schizophrenia. With the introduction of the Chronic Disease
The longitudinal course of schizophrenia is variable. Management Programme (CDMP) in Psychiatry, the care
Complete remission with a full return to a premorbid level of stable patients with schizophrenia is being transferred to
of functioning is not common, although some individuals general practitioners in primary care, and these guidelines
are free from further episodes. The outcome following will serve as a useful resource for them.
first admission and first diagnosis of schizophrenia with
follow-up time of more than one year suggests that less 1.5 Development process of this guideline
than 50% of patients have a good outcome – this is thought This guideline was developed by a multidisciplinary
to be due to unexplained heterogeneity rather than uniform workgroup appointed by the Ministry of Health, Singapore.
poor outcome. A small proportion (10%–15%) will remain The workgroup consisted of a family practitioner, a
chronically and severely psychotic. Early detection and family therapist, a healthcare administrator, occupational
treatment, however, would lead to a better outcome. therapists, a patient advocate, pharmacists, psychiatrists
The management of schizophrenia should take a and psychologists. This guideline was developed by
holistic and multidisciplinary approach. The type and range reviewing relevant literature, adapting existing guidelines
of intervention is, to a large extent, specific to the different and by expert clinical consensus with consideration of local
phases of the illness. In the acute phase of the illness, the practice.
patient requires specialised psychiatric care.
Family physicians play an important role in the 1.6 What’s new in this revised guideline
early detection of those who are psychotic. They are also • The chapter on treatment of acute symptoms has been
important in managing patients who are stabilised but enhanced by recommendations for first-episode and
require maintenance pharmacotherapy. Most of these relapse of schizophrenia.
stabilised patients are best managed in the community. • The chapter on maintenance pharmacotherapy has been
 Singapore Med J 2011; 52(7) : 523

enhanced with recommendations for monitoring of algorithm in Annex II) (pg 12).
metabolic side effects and combining antipsychotics. Grade D, Level 4
• The chapter on psychosocial rehabilitation has
new recommendations on rehabilitation, cognitive A Oral antipsychotics should be used as first-line
remediation therapy and assertive community treatment for patients with an acute relapse of
treatment. schizophrenia (pg 13).
Grade A, Level 1++
1.7 Review of guidelines
Evidence-based guidelines are only as current as the GPP Choice of antipsychotic should take into account
evidence that supports them. Users must keep in mind that the patient’s previous treatment response,
new evidence could supercede recommendations in this side effect experience, comorbid conditions,
guideline. The workgroup advises that this guideline be compliance history and preference (pg 13).
scheduled for review five years after publication, or when GPP
new evidence appears that requires substantive changes to
the recommendations made in this guideline. Maintenance pharmacotherapy
A For maintenance therapy, antipsychotic dose
Executive summary of recommendations should be reduced gradually to the lowest possible
Details of the recommendations listed can be found in the effective dose, which should not be lower than half
main text as the pages indicated. of the effective dose during the acute phase (pg 14).
Grade A, Level 1+
Treatment of acute symptoms
GPP The preliminary step in management involves B Combination of antipsychotics is not recommended
establishing diagnosis and ruling out psychoses except during transitional periods when patients are
that could be secondary to physical morbidity being switched from one antipsychotic to another,
or substance use. The patient’s social supports, or when used for clozapine augmentation (refer to
functioning and relative risk of self-harm or harm Annex II) (pg 14).
to others must be evaluated for choice of treatment Grade B, Level 2++
setting (pg 11).
GPP C Long-acting depot antipsychotics may be indicated
in patients in whom treatment adherence is an issue
A People newly diagnosed with schizophrenia should or when a patient expresses a preference for such
be offered oral antipsychotic medication (pg 11). treatment (pg 14).
Grade A, Level 1++ Grade C, Level 2+

GPP Clinicians must provide information and discuss B Long-acting depot antipsychotics should not be used
the benefits and side effect profile of each drug with for acute episodes because it may take 3–6 months for
the patient (pg 11). the medications to reach a stable steady state (pg 15).
GPP Grade B, Level 2++

A The recommended optimal oral dose of C Patients receiving atypical antipsychotics should
antipsychotic is 300–1,000 mg chlorpromazine be regularly monitored for metabolic side effects
equivalents daily for an adequate duration of 4–6 (refer to Annex III) (pg 15).
weeks. Treatment should be started at the lower end Grade C, Level 4
of the licensed dosage range and slowly titrated
upwards (refer to table in Annex II) (pg 12). Management of treatment-resistant schizophrenia
Grade A, Level 1++ A Clozapine should be offered to patients whose
illness has not responded adequately to treatment
D If there is inadequate response by 4–6 weeks or despite the sequential use of adequate doses and
if patient develops intolerable side effects, the duration of at least two different antipsychotics
medication should be reviewed and another typical (pg 16).
or an atypical antipsychotic should be used (refer to Grade A, Level 1++
 Singapore Med J 2011; 52(7) : 524

GPP For all patients on clozapine, clinicians should have A Early psycho-education and family intervention
their full blood count monitored weekly for the first should be offered to patients with schizophrenia and
18 weeks and monthly thereafter (pg 16). their families (pg 22).
GPP Grade A, Level 1+

D Electroconvulsive therapy should be considered B Sheltered, transitional or supported employment

for patients who have not responded to an adequate should be offered to patients with schizophrenia as
trial of antipsychotics and for patients with life- part of a psychiatric rehabilitation programme to
threatening symptoms such as catatonia and enhance their vocational skills (pg 22).
prominent depressive symptoms (pg 16). Grade B, Level 2++
Grade D, Level 3
A Cognitive remediation may be considered to improve
A Electroconvulsive therapy should not be attention, memory and executive function among
prescribed as first-line treatment or monotherapy in people with schizophrenia (pg 23).
schizophrenia (pg 17). Grade A, Level 1+
Grade A, Level 1+
A Cognitive remediation should be provided by
Adjunctive medications occupational therapists within the framework of
A Antidepressants should be considered when a psychiatric rehabilitation programme, with a
depressive symptoms emerge during the stable functional goal in mind (pg 23).
phase of schizophrenia (post-psychotic depression) Grade A, Level 1+
(pg 18).
Grade A, Level 1+ A Psychological therapy, in particular Cognitive
Behaviour Therapy (CBT), administered in
D Antidepressants should be used at the same dose as combination with routine care should be considered
for treatment of major depressive disorder (pg 18). for patients with schizophrenia, particularly those with
Grade D, Level 4 persistent negative and positive symptoms (pg 23).
Grade A, Level 1+
A Anticholinergic agents have been shown to be
effective in reducing the severity of antipsychotic- A Assertive Community Treatment should be
induced extrapyramidal side effects and may be recommended for patients with high rates of
prescribed to patients experiencing these side effects hospitalization as well as for those patients with a
(pg 19). high potential for homelessness (pg 24).
Grade A, Level 1+ Grade A, Level 1+

Psychosocial interventions Pregnancy

GPP Psychosocial interventions should be tailored to the D Treatment options for schizophrenia patients
needs of the patients (pg 21). who are pregnant should be individualised, with
GPP consideration of severity of previous episodes,
duration of remission since last episode, response to
A Patients and their family members should be treatment and the woman’s preference after full and
educated about the illness, its course and prognosis informed discussion (pg 25).
as well as the efficacy of the various medications, Grade D, Level 4
the anticipated side effects and costs. Family
interventions should also incorporate support, GPP Schizophrenia patients who are pregnant should be
problem-solving training and crisis intervention referred for urgent specialist consultation if they
(pg 21). have not been seen by a specialist before (pg 25).
Grade A, Level 1+ GPP
 Singapore Med J 2011; 52(7) : 525

GPP Abrupt cessation of medications should be avoided D Healthcare providers should provide psycho-
in schizophrenia patients who are pregnant, as it education to women with schizophrenia in the
can increase the risk of relapse, particularly in the childbearing age group on the risk considerations in
early weeks of pregnancy when hormonal changes pregnancy and counsel patients on family planning
make the woman more vulnerable (pg 25). and sexuality issues, as appropriate (pg 26).
GPP Grade D, Level 4
 Singapore Med J 2011; 52(7) : 526

SINGAPORE MEDICAL COUNCIL CATEGORY 3B CME PROGRAMME

Multiple Choice Questions (Code SMJ 201107B)

These questions are based on the full text of the guidelines which may be found at http://www.moh.gov.sg/mohcorp/
publications.aspx?id=26138.

True False
Question 1. The following is true of the treatment of schizophrenia in pregnancy and the postpartum:
(a) All psychotropic medication must be stopped. ☐ ☐
(b) There is a risk of relapse in the postpartum. ☐ ☐
(c) Care should also be taken to look out for postpartum depressive states. ☐ ☐
(d) Breastfeeding is absolutely contraindicated. ☐ ☐

Question 2. Regarding electroconvulsive therapy:
(a) It is used as a first-line therapy for schizophrenia. ☐ ☐
(b) It is more effective than antipsychotics in the acute treatment of schizophrenia. ☐ ☐
(c) It is effective in the treatment of chronic schizophrenia. ☐ ☐
(d) It may be considered in patients who have not responded to an adequate trial of antipsychotic ☐ ☐
therapy.

Question 3. Regarding the use of anticholinergic agents:

(a) They are effective in treating antipsychotic induced extrapyramidal side effects such as ☐ ☐
dystonia and parkinsonism.
(b) Other interventions to reduce the burden of extrapyramidal side effects include raising the dose ☐ ☐
of antipsychotics.
(c) The prophylactic use of anticholinergics may be considered for those patients needing higher ☐ ☐
doses of antipsychotics.
(d) The use of anticholinergics do not carry any inherent risks. ☐ ☐
Question 4. Psychological therapy can assist patients with schizophrenia through:
(a) Helping to reduce the severity of symptoms. ☐ ☐
(b) Addressing related issues such as anxiety and depression. ☐ ☐
(c) Improving coping skills. ☐ ☐
(d) Eliminating stress and negative thoughts. ☐ ☐
Question 5. Antipsychotic medications:
(a) Start showing response by two weeks, and sometimes take several weeks to achieve remission. ☐ ☐
(b) Clinicians should wait for at least for one year before considering switching to another ☐ ☐
antipsychotic if there is no response to the first antipsychotic medication.
(c) Atypical antipsychotics are superior to typical antipsychotics in terms of efficacy. ☐ ☐
(d) Typical antipsychotics have more propensity to cause extrapyramidal side effects than atypical ☐ ☐
antipsychotics.

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