VOL. 5, SPECIAL ISSUE THE AMERICAN JOURNAL OF MANAGED CARE SP47 . . . PAPER PRESENTATION . . . Implementing Effectiveness Research and Improving Care for Schizophrenia in Real-World Settings Peter F. Buckley, MD; Alexander Miller, MD; John A. Chiles, MD; and Martha Sajatovic, MD Abstract Objective: To review recent advances in medica- tion practices and standards of care in the treatment of schizophrenia and examine the disparity between the knowledge base and clinical practice. Data Sources: Key literature on medication prac- tices, novel pharmacotherapies, and the evolution of practice guidelines for schizophrenia were reviewed. Discussion: Emerging data demonstrate a lack of consistent application of current knowledge and best practices, in part due to major structural incon- sistencies in the public mental health system. Implementation of results from effectiveness research as well as the incorporation of practice guidelines may help bridge this gap. Conclusion: As standards of care for schizophre- nia are developed, the following issues will need particular attention: coordination with the criminal justice system, comprehensive treatment of comor- bid illnesses, outcomes based on symptoms in all domains, and continuous and integrated collection of data to produce rational cost justification. (Am J Managed Care 1999;5:SP47-SP56) From Northcoast Behavioral Healthcare System and Case Western Reserve University, Cleveland, OH (P.F.B., M.S.); University of Texas Health Science Center at San Antonio (A.M., J.A.C.); and San Antonio State Hospital, San Antonio, TX (A.M.). Address correspondence to: Peter F. Buckley, MD, Associate Professor of Psychiatry, Case Western Reserve University, University Hospitals of Cleveland, 11100 Euclid Ave, Cleveland, OH 44106. O ver the past 10 years there have been major changes in the treatment and management of schizophrenia. They have had a substan- tial impact on our understanding of this serious dis- order, as well as our expectations about its outcome. By contrast, from the mid 1950s through the 1980s, available biologic therapies for the treatment of schizophrenia remained relatively static. This changed in 1990 with the introduction of the atypi- cal antipsychotic clozapine, which had demonstrat- ed efficacy in patients with previously treatment- refractory schizophrenia. 1 However, use of clozapine was limited in clinical settings by side effects. Since the introduction of clozapine, a series of novel antipsychotic compounds (risperidone [1994], olanzapine [1996], and quetiapine [1997]) were approved by the FDA for the treatment of psychosis; and several others are in advanced stages of clinical development. 1,2 These novel antipsychotics are asso- ciated with fewer drug-related adverse effects com- pared with older, conventional antipsychotic agents and may lead to improved reduction of symptoms of schizophrenia as well (Table 1). Although encouraging, the advent of these drugs has come amidst a marked gap in knowledge between outcomes in the research setting and out- comes in real-world clinical practice. 3 Drug trials involving novel antipsychotics have primarily involved carefully screened patients with no comor- bid psychiatric or medical conditions, who were treated in academic or research-oriented medical centers. Drug treatment in research settings tends to be short term and focused on side effects and symp- toms. Individuals who are likely to be noncompliant with treatment regimens or who are unable to partic- ipate in focused interviews or rating questionnaires are usually excluded from participation.