Web-based tool to help clinicians make schizophrenia treatment decisions

December 29, 2004

A new Web-based tool will be available January 1, 2005 to help clinicians determine the best medication for patients with schizophrenia. An international team led by Vanderbilt University Medical Center's Herbert Meltzer, M.D., recently completed the new algorithms, or step-by-step protocols, which will provide clinicians a resource as they make treatment decisions.

The value of the algorithms was recently acknowledged by the World Health Organization (WHO), which has committed to establishing a Web link to the algorithms from its Web site. This will allow clinicians and patients worldwide to access the algorithms.

The International Psychopharmacology Algorithm Project (IPAP), a team of psychiatrists, psychopharmacologists and algorithm designers, was founded by Knoxville, Tenn. psychiatrist Kenneth Jobson, M.D., to develop new Web-based tools to improve the treatment of psychiatric disorders. In 2000, Meltzer joined in their efforts and organized a group to develop the algorithms for schizophrenia treatment.

"The idea was that we would come up with evidence-based medicine for schizophrenia, providing clinicians with a resource as they make decisions in standard situations, as well as in crises like suicidality, violence, and severe drug side effects," said Meltzer, the Bixler/Johnson/Mays Professor of Psychiatry and director of the Division of Psychopharmacology.

The algorithms are unique in many ways, Meltzer said. First, they require clinicians to evaluate patients for these crises before deciding on the course of drug therapy. Also, the algorithms are designed to help clinicians who are not psychiatrists evaluate a patient's medication regimen.

"The kind of people now prescribing drugs include nurse practitioners, as well as family doctors," Meltzer said. In addition, patients are often seen infrequently on an outpatient basis under managed care. Such changes have led to serious problems, which includes patients not using medications correctly and/or using multiple drugs without good evidence that multiple drugs should be used. "Among patients with schizophrenia, around 20 percent are taking two or more antipsychotics," Meltzer said.

"Algorithms have come into favor to give strong guidance to people who aren't fully knowledgeable about the literature or have very limited time with patients."

This double- and triple-treatment, known as polypharmacy, leads to higher drug costs, both to traditional insurance plans and governmental health care plans like TennCare, Tennessee's Medicaid program. The IPAP algorithms are designed to limit this phenomenon of polypharmacy, which Meltzer expects will lead to a tremendous savings in drug costs.

"Following the algorithms could save a minimum of 40 percent on the antipsychotics for schizophrenia," estimated Meltzer. Regarding the TennCare budget crisis, Meltzer added, "I think (use of the algorithms) could provide a way of reducing the cost of psychotropic drugs to the state."

Meltzer's current research also suggests that limiting polypharmacy improves patient outcomes. In a study set to be published in the spring, Meltzer and colleagues found that adding a placebo to the standard antipsychotic medication, Clozaril, was better than adding a second antipsychotic in terms of improving psychosis and cognitive function. These findings strongly advocate limiting the use of multiple drugs.

"I think patients will get much better care," Meltzer said.

"We are excited to be involved in the implementation of these algorithms," said Karen Rhea, M.D., vice president for Medical Services at Centerstone, the largest behavioral health care provider in Tennessee. With approximately 2,000 schizophrenic patients seen by providers in the Centerstone system, the availability of such a tool will be a highly valuable asset to mental health care in the state.

"We are particularly pleased with their being available online. It's going to make it much simpler for us to implement," Rhea said. "As our system is completely paperless, this is a modality we use anyway, and will allow our providers to quickly access the portions of the algorithms that are of interest."

Another strength of the IPAP algorithms is their incorporation of evidence-based medicine. "Protocols and algorithms are one source of collecting information from the literature," Jobson said. "And information from the literature is one of the data streams used to make clinical decisions.

"So this will provide, we hope, salient information for health care providers in this country and abroad, to have the opinion of a large group of international experts on best treatment practices."

The Web-based format will allow health care providers to not only see the recommendations, but also see the level of supporting evidence and the references that back those recommendations up.

However, cautioned Jobson, "It is not prescriptive in the sense of being a recommendation for any single patient."

Being Web-based, the IPAP algorithms can also be easily adapted to reflect the results of the most recent research advances -- a problem inherent in print-based algorithms. Its Web-based format also allows the algorithms to be adapted for use by clinicians in any country.

"We devised a number of variations on the algorithms for different countries where the same medications are not available," Meltzer said.

"Dr. Meltzer was able to recruit an extraordinary faculty through his international work, his international contacts," said Jobson. "It's the most international a faculty that's ever addressed schizophrenia, certainly in a Web-based way."

To access the algorithm, visit www.ipap.org.

Vanderbilt University Medical Center

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