Translating the psychopharmacology of antipsychotics to individualized treatment for severe mental illness: a Roadmap

Abstract

Objectives: The goal of the Roadmap is to provide guidance on how to use currently available antipsychotics to achieve best outcomes for patients with serious mental illness. The Roadmap orientation is that clinicians often make treatment decisions based on their underlying model of the illness. The Roadmap therefore begins with a review of two theoretical models often used by clinicians who treat patients with severe mental illness (Section II). The "maintenance model" emphasizes achieving clinical stability; once the patient is stable, this model gives priority to relapse prevention and maintenance of stability. The "recovery model" also aims for achieving stability, but it places more emphasis on achieving further gains in physical and emotional health once stability is achieved. While a simplification, these models are based on different assumptions about the course and outcome of schizophrenia and the potential risks and benefits of different pharmacologic treatment options. These treatment models serve as the framework for the Roadmap recommendations, which are based on the clinical and psychopharmacologic research literature as well as expert consensus on questions not definitively answered in that literature.

Methods: On the basis of results of an initial survey and a roundtable meeting, a panel of 10 experts developed a list of psychopharmacologic topics not adequately addressed by the evidence-based literature, but which clinicians who use antipsychotic medications need to understand. These questions were posed in a survey to a larger panel of 32 experts, 27 (84%) of whom responded. Results of this survey and data from the literature were then used to develop recommendations for applying psychopharmacologic principles to individualize treatment for patients with severe mental illness.

Results: Recommendations are presented to help clinicians make informed decisions about choice of medication, dosing, and switching strategies, based on the pharmaco-dynamic and pharmacokinetic properties of different antipsychotics (Section III); diagnosis, prominent symptoms, and treatment history (Section IV); the patient's age, gender, and psychosocial characteristics (Section V); and the patient's medical conditions whether related to antipsychotic treatment or not (Section VI). The final section illustrates how to apply the principles presented in the first six sections in real-world clinical situations.

Conclusions: The experts reached a high level of consensus on many key questions about treatment strategies. The Roadmap recommendations provide guidance for clinicians on how to fine-tune their psychopharmacologic strategies with antipsychotics to achieve the best outcomes for each individual patient.