2020年美国精神医学会APA实践指南：精神分裂症的治疗(第3版)中文版第一部分

抗精神病药是精神分裂症治疗的重要组成部分，其选择依赖于很多因素，而这些因素 因具体患者而异。因此，作为选药的一部分，医生在开始抗精神病药治疗前应采集有关患 者治疗偏好及既往治疗反应的信息，随后与患者讨论一种药物相比于其他治疗手段的潜在 获益和风险。很多患者希望家人或其他人也参与到讨论中，为其提供支持。讨论的深度无 疑取决于患者的实际情况。即便是激越患者，以及存在思维障碍的患者，如果能够找到那 些造成主观痛苦且抗精神病药可以治疗的靶症状，如焦虑、眠差，或存在自知力的患者的 幻觉妄想，医患联盟同样能够得到强化。向患者提及发生急性副作用（如，头晕、镇静、 不宁等）的可能性，也可以帮助其发现及报告副作用，并可能有助于维持治疗联盟。精神 分裂症患者常存在注意及其他认知功能的损害，且在病情急性加重时可能更显著；伴随着 治疗的进行，医生需要不时将话题引回针对靶症状及副作用的讨论上来。
表 6 抗精Choice of an Antipsychotic Medication
影响选药的因素
Available Drug Formulations
可用剂型
Medication choice may be influenced by available formulations of specific medications, such as oral concentrates or rapidly dissolving tablets for patients who have difficulty swallowing pills or who are ambivalent about medications and inconsistent in swallowing them. Use of ingestible sensors with associated monitoring technology may assist in evaluating ingestion, although the FDA notes that improvements in adherence have not yet been shown (U.S. Food and Drug Administration 2017). LAI formulations may be preferred by some patients (Heres et al. 2007; Patel et al. 2009; Walburn et al. 2001) and may be particularly useful for patients with a history of poor or uncertain adherence (see Statement 10). Short-acting parenteral formulations of antipsychotic agents are available for short-term use in individuals who are unable to take oral medications or for emergency administration in acutely agitated patients.
美国精神医学学会 APA 新版精神分裂症治疗指南第一部分
Selection of an Antipsychotic Medication
选择抗精神病药
General Principles
总体原则
In the treatment of schizophrenia, antipsychotic medication is one important component. The choice of an antipsychotic agent depends on many factors that are specific to an individual patient. Thus, before initiating treatment with antipsychotic medication, it is recommended that as part of selecting a medication, the treating clinician gather information on the patient’s treatment-related preferences and prior treatment responses and then discuss with the patient the potential benefits and risks of medication as compared with other management options. Many patients will wish family members or other persons of support to be involved in this discussion. The depth of this discussion will, of course, be determined by the patient’s condition. Even with agitated patients and patients with thought disorder, however, the therapeutic alliance will be enhanced if the patient and physician can identify target symptoms (e.g., anxiety, poor sleep, and, for patients with insight, hallucinations and delusions) that are subjectively distressing and that antipsychotics can ameliorate. Mentioning the possibility of acute side effects (e.g., dizziness, sedation, restlessness) helps patients identify and report side-effect occurrence and also may help maintain a therapeutic alliance. Patients with schizophrenia often have attentional and other cognitive impairments that may be more severe during an acute illness exacerbation, so it is helpful to return to the topic of identification of target symptoms and discussion of acute and longer-term side effects on multiple occasions as treatment proceeds.
compared with another. Consequently, the choice of a particular antipsychotic agent will typically occur in the context of discussion with the patient about the likely benefits and possible side effects of medication options and will incorporate patient preferences; the patient’s past responses to treatment (including symptom response and tolerability); the medication’s side-effect profile (see Table 6); the presence of physical health conditions that may be affected by medication side effects; and other medication-related factors such as available formulations, potential for drug-drug interactions, receptor binding profiles, and pharmacokinetic considerations (Tables 3–9).
An evidence-based ranking of FGAs and SGAs or an algorithmic approach to antipsychotic selection is not possible because of the significant heterogeneity in clinical trial designs, the limited numbers of head-to-head comparisons of antipsychotic medications, and the limited clinical trial data for a number of the antipsychotic medications. By the same token, it is not possible to note a preference for either SGAs or FGAs. Although there may be clinically meaningful distinctions in response to and tolerability of different antipsychotic medications in an individual patient, there is no definitive evidence that one antipsychotic will have consistently superior efficacy compared with another, with the possible exception of clozapine. Although data in first-episode schizophrenia are more limited, there appears to be no difference in response among the SGAs that have been studied (McDonagh et al. 2017; Zhu et al. 2017). Furthermore, there is no reliable strategy to predict response or risk of side effects with one agent