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Behavioral Health – Schizophrenia Visit Guideline and Clinical Protocol
Strength of Evidence Level: 3
PURPOSE:
To establish guidelines and clinical protocol for a visit
with a patients with schizophrenia.
EQUIPEMENT:
None
OVERVIEW
Schizophrenia is a mixture of positive and negative
symptoms that present for a significant portion during a
1 month period but persists for at least 6 months.
Several subtypes exist. The clinical picture is complex
and symptoms may differ in an individual from episode
to episode. The natural progression of schizophrenia is
deterioration over time with an eventual plateau in the
symptoms. It is a chronic brain disease. The goals of
treatment in the Behavioral Health Homecare Program
are to reduce stress on the patient and provide support
for the following:
1. Relapse prevention through symptom reduction.
2. Minimize likelihood of relapse (crisis rehospitalization and emergency room visits).
3. Promote functional improvement and adherence to
plan of care.
PROCEDURE:
Tools Used to Determine Medical Necessity
Based upon presenting signs and symptoms various
tools will be administered to the patient at the evaluation
visit, upon start of care to the program and at discharge.
All patients will receive the Brief Psychiatric Rating
Scale and when anti-psychotics are ordered, the
Abnormal Involuntary Movement Scale.
1. Aggression Scale: Administered if the patient
exhibits aggression. It measures the amount and
type of aggression exhibited. The score
corresponds to an acuity level. Interventions and a
behavioral plan should be implemented to reduce
the incidence and frequency of the behavior.
2. Abnormal involuntary movement scale (AIMS):
Used for all patients who are on an anti-psychotic
medication. The score corresponds to an acuity
level. Interventions are implemented based on the
acuity.
3. Brief psychiatric rating scale (BPRS): Rates
psychiatric behaviors and symptoms for patients
with major mental illness. The score corresponds to
an acuity level. Interventions are implemented
based on acuity.
4. SAD PERSONS suicide risk assessment: A scale
used to assess the likelihood of a suicide attempt,
based on risk factors.
5. Geriatric depression scale (GDS) or Patient
health questionnaire (PHQ9) – See Depression
Visit Guideline/Clinical Protocol.
a. Core Symptom Clusters:
(1) Positive symptoms - Excess or distortion
of normal function.
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 Hallucinations.
 Delusions.
 Thought disorder.
 Disorganized speech.
 Bizarre behavior.
 Inappropriate affect.
(2) Negative symptoms - Lessening or loss of
normal functions
 Affective flattening.
 Alogia.
 Avolition, apathy.
 Anhedonia, asociality.
 Attentional deficit.
(3) Neurocognitive impairment
 Memory.
 Attention, vigilance.
 Executive functions, abstraction,
concept formation, problem solving,
decision making.
(4) Mood symptoms
 Dysphoria.
 Suicidality.
 Hopelessness.
Phases of Schizophrenia Treatment and Associated
Treatment Goals
1. Acute-1-3 days- Goal is to control agitation and
behavior and provide safety. Most often, these
patients are hospitalized.
2. Stabilization-7-14 days- Goal is to stabilize
positive, negative and depressive symptoms,
establish a medication regime and teach/educate
(first 7 to 10 days usually is performed by inpatient
staff then patient is discharged to the community).
This is a vulnerable time; although positive
symptoms have improved some positive symptoms
remain.
a. During this time the person would benefit from a
Behavioral health intervention.
b. The admission of a patient: 1) from an in-patient
unit who will be at the end of the stabilization
phase of treatment and the early portion of the
stable phase or 2) medically ill patients with a
concurrent diagnosis of schizophrenia and with
an acute symptom exacerbation of the chronic
mental illness.
3. Stable – 6 months or more-Goal is to improve
symptoms particularly negative; enhance global
functioning; psychotherapy; psycho education;
promote reintegration; prevent relapse.
a. In this phase the behavioral interventions will
provide services for a defined period of time.
For example, 1-2 episodes followed by a
referral to out patient psychiatric services for
on-going monitoring and treatment.
Co-Morbid Medical Illness or Risks Associated with
Schizophrenia:
Behavioral Health – Schizophrenia Visit Guideline and Clinical Protocol
Strength of Evidence Level: 3
This is pervasive in schizophrenia and leads to a
significant decrease in the life span for schizophrenics.
1. Elevated rates of cardiovascular mortality due to
multiple risk factors.
2. Weight gain during antipsychotic treatment leads to
predictable disturbances in glucose and lipid
metabolism and increase cardiovascular risk.
Emergent Care Issues/Risk Assessment Associated
with Schizophrenia:
1. Suicidal Ideation-Suicide is the leading cause of
premature death among patients with
schizophrenia. Evaluate risk on a regular basis.
2. Aggressive behavior-A minority of patients have
an increased risk. The risk increases with co-morbid
alcohol (ETOH) abuse, substance abuse, antisocial
personality or neurological impairment. Identify risk
factors and evaluate behavior on a regular basis.
3. Water Intoxication-polydipsia and polyuria.
4. Neuroleptic Malignant Syndrome-medication
emergency.
5. Acute Dystonic Reaction.
Commonly Used Medications: (not a complete list)
1. Anti psychotic medicationsAdjunctive
medications:
b. Benzodiazepines-Clonazepam (Klonopin),
Lorazepam (Ativan).
c. Anti-depressants- Sertraline (Zolft),
Citalopram (Celexa), Amitriptyline, Duloxetine
(Cymbalta), Venlafaxine (Effexor), Selegiline
(Emsam).
d. Mood stabilizers- Divalproex (Depakote),
Carbamazepine (Tegretol), Valproate
(Depakene), Lamotrigine (Lamictal),
Gabapentin (Neurontin), Topiramate
(Topamax).
2. Beta-blockers
a. Specific and actual teaching/training
interventions are defined below: These
interventions are inclusive of categories that will
ensure overall safe and quality care for the
patient with schizophrenia and are defined by a
recommended visit occurrence.
Visit recommendations are based upon the necessity
and urgency of the information provided and the ability
of the patient to learn and understand the information.
Management Transition from Stabilization to Stable
Treatment Phase:
1. Clinician will make between 5-18 visits for a period
of one (1) to two (2) episodes.
2. The visit frequency most likely will be once a week
(QW) or twice a week (BIW) initially for more
symptomatic patients.
Assessment/Interventions:
Every Visit:
1. Mental status evaluation.
2. Vital signs.
3. Weight.
4.
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Presence/severity of symptoms impairing
functioning(e.g.-self care):
a. Positive symptoms.
b. Negative symptoms.
c. Neurocognitive impairment.
d. Mood symptoms.
e. Suicidal ideation/risk.
(1) Identify target symptom(s)
(a) Have patient score target symptoms on
a scale of 0-10 each visit.
(b) Observe for resurgence of symptoms.
(2) Assess for treatment non-adherence
behaviors.
(3) Medication compliance with anti-psychotic
and adjunctive medication.
(4) Lab test results
(a) CBC for patients treated with
clozapine.
(b) Consult with treating provider for
appropriate lab monitoring.
f. Subjective distress due to side effects of the
medication-this impacts on adherence to
treatment (see below)
(1) Extrapyramidal (EPS) side effects
(2)
Pseudoparkinsonism: masklike facies,
stiff and stooped posture, shuffling, gait,
drooling, tremor, “pill-rolling” phenomenon.
(3) Acute Dystonic Reactions: Acute
contractions of tongue, face, neck and back
(tongue and jaw first).
(4) Akathisia: Motor inner-driven restlessness
(foot tapping incessantly, rocking forward
and backward in chair, shifting weight from
side to side).
(5) Tardive Dyskinesia:
(6) Facial: Protruding and rolling tongue,
blowing, smacking, licking, spastic facial
distortion, smacking movements.
(7) Limbs:
(a) Choreic: rapid, purposeless, and
irregular movements.
(b) Athetoid: Slow, complex, and
serpentine movements.
(c) Trunk: Neck and shoulder movements,
dramatic hip jerks and rocking, twisting
pelvic thrusts.
Teaching /Training Topics
1. Disease process:
a. Course and Outcome.
b. Causation-several accepted models.
(1) Brain structure and functioning.
(2) Genetics.
(3) Psychological stress.
(4) Environmental.
(5) Vulnerability stress.
c. Psychopharmacologic agents-include drug
action, dosage, frequency, possible adverse
effects and importance of adherence. Link
Behavioral Health – Schizophrenia Visit Guideline and Clinical Protocol
Strength of Evidence Level: 3
positive effects of medication with patients
goals.
Self care activities:
1. Hygiene.
2. Prevent/reverse weight gain (anti psychotics, mood
stabilizers and anti depressants can all cause
weight gain). Be cognizant of hypertension, lipid
abnormalities, clinical symptoms of diabetes, fasting
glucose, hemoglobin A1c levels.
3. Assess need for nutritional services consult.
a. Patient self management strategies.
(1) Self monitoring of symptoms.
(2) positive, negative, cognitive impairments.
b. Teach behavioral strategies.
(1) Nutrition (e.g., monitor calorie intake,
portion control).
(2) Activity and exercise (e.g., increase
activity).
c. Identify and address occurrence of life
stresses and events that.
(1) Increase the risk of relapse.
(2) Are obstacles to functional recovery
d. Family Education.
e. Decrease family/caregiver stress.
f. Family psycho education (as indicated).
Perform Skilled Cognitive Behavioral Therapy (CBT)/
Psychotherapy Techniques:
CBT is typically used as an adjunct to pharmacotherapy
and involves identifying maladaptive cognitions and
behaviors that may be barriers to a person’s recovery
and symptom reduction. In treating schizophrenia CBT
techniques are used to treat positive and negative
symptoms, to treat co morbid depression and anxiety,
for relapse prevention and to establish step by step
plans to cope with symptoms and stress of daily life and
any setbacks.
1. Establish a strong therapeutic alliance.
a. Acceptance support, collaboration.
2. Develop and prioritize problem list.
a. Target Symptoms (include negative and
positive).
b. Treatment goal-management of symptoms.
3. Educate and normalize symptoms.
a. Disease process.
b. Medication acceptance/adherence.
c. Role of stress on symptoms.
d. Decrease mental illness stigma through
education.
4. Educate about CBT.
a. Identify links between thoughts, feelings and
behaviors.
b. Identify themes from the problem list.
c. Share formulation and cognitive focus with
patient.
5. CBT for Positive and Negative Symptoms.
a. Test and re-frame beliefs.
b. Weigh the evidence.
c. Alternative explanations.
6.
7.
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d. Behavioral experiments.
e. Elicit self-beliefs.
f. Investigate hierarchy of fears and suspicions.
g. Use images.
h. Use role playing.
i. Coping strategies.
CBT for Co-Morbid Depression and Anxiety.
a. Adapt standard strategies for anxiety and
depression.
b. Test and reframe beliefs related to anxiety and
depression.
c. Focus on misinterpretations.
d. Use relaxation exercises.
e. Use activity exercises.
Relapse Prevention.
a. Identify triggers/hi risk situations
b. Compliance with medication regimen. Teach
patient:
(1) to report side effects ASAP.
(2) the benefit of medication to decrease
symptoms.
(3) to obtain family assistance in monitoring
adherence.
(4) to use environmental supports to cue and
reinforce medication taking.
c. Responsiveness of supports (formal and
informal).
d. Establish step-by-step action plan to deal with
setbacks.