The Schizophrenia Algorithm

To the Editor: The authors of the article describing the development and implementation of the schizophrenia algorithm (1) in the January issue are to be congratulated on a useful and readable presentation. However, I have some questions about some of the stages of the algorithm. For stage 1, where there is "no history of typical antipsychotic failure," the algorithm indicates a switch to "olanzapine or quetiapine or risperidone." This course seems a bit uncompromising. What about a patient with chronic schizophrenia who has done well on small doses of typical antipsychotics, is not on anticholinergics, and manifests no adverse side effects? Should such a person be switched?

In stage 6, the use of "atypical plus typical, or combination of atypicals, or typical or atypical plus ECT" is problematic in the sense that it is far too inclusive. Patients who respond to combinations of medications should not be lumped together with patients who require electroconvulsive therapy, either alone or in combination with medications. It seems to me stage 6 should be subdivided into several categories.

Also, I would question why in stage 5 clozapine is listed as an algorithmic option before the choice of using a combination of medications as represented in stage 6. It seems to me that a combination of two antipsychotics, either typical or atypical, in any permutation is less hazardous, less expensive, and less inconvenient to the patient than clozapine, which requires biweekly, weekly, and sometimes twice-weekly white blood cell counts. Why not offer combination therapy before clozapine therapy unless there is an a priori theoretical bias against combinations? I thought the days of regarding all forms of polypharmacy as intrinsically evil were over. Possibly this sequence exists because stage 6 was not subdivided into non-ECT and ECT categories.

It is in the middle stages that the algorithm is most useful, and I find myself referring to it in my own progress notes, written in California as if the eyes of Texas were upon me. I believe this to be the highest form of compliment, so congratulations again to the authors.

Dr. Fleishman is in private practice in San Francisco.