Rethinking Schizophrenia Care

What the INTEGRATE guidelines mean for Australian clinicians

Schizophrenia remains one of the most complex and burdensome psychiatric disorders worldwide, affecting nearly one in 150 people over their lifetime. While treatments are available, delays in delivering optimal care, treatment resistance, and the high burden of side effects have long challenged both patients and clinicians. In response to these issues, a global consortium of experts has released the newly published INTEGRATE Guidelines, a landmark, internationally developed, algorithmic approach to pharmacological schizophrenia management – the first of its kind. Designed with input from 30 countries (including our own RANZCP), and individuals with lived experience, this comprehensive framework may shift how schizophrenia is treated in Australia.

Australia has traditionally relied on relatively outdated national guidelines for the treatment of schizophrenia. While these documents have provided valuable evidence-based direction, they are often lengthy, inconsistent, lacking clarity, and may not reflect current international consensus or rapid shifts in practice – and that’s the primary concern. With more rigorous and intentional data coming out around treatment outcomes, it’s only fair that we see the guidelines evolve and differentiate to the Australian population. A 2022 review revealed significant gaps in existing guidance, including limited direction on the management of negative symptoms and treatment-resistant schizophrenia (which is widely-accepted as a growing concern). In addition, there was often ambiguity around the timing of treatment changes when response was inadequate. The INTEGRATE Guidelines address these limitations by offering a concise, globally relevant, stepwise treatment approach. Importantly, the guidelines are complemented by a digital tool, enabling clinicians to input clinical variables and receive tailored guidance in real time.

Future-proofed and clear

The foundation of the guidelines is a commitment to shared decision making. Individuals with schizophrenia, along with their carers and support networks, should be actively involved in treatment planning from the outset. Early discussions around medication options, anticipated benefits, side-effect profiles, and potential use of long-acting injectable formulations are essential to fostering engagement and supporting adherence. This was raised as a primary concern of the old guidelines, and formed the basis of why patient input was low. This new patient-led approach aligns with Australia’s broader movement toward consumer-centred mental health care and reinforces the importance of collaborative practice.

A key focus of the guidelines is the treatment of first-episode psychosis. For patients experiencing their first psychotic episode, the guidelines recommend initiating antipsychotic treatment if symptoms persist beyond one week and cause distress or impairment, unless clearly attributable to substance use or a medical condition. Treatment choices should reflect not only symptom profile but also patient preference, side-effect risk, and long-term physical health considerations. The guidelines highlight the need to proactively mitigate cardiometabolic risk from the outset, recommending concurrent lifestyle support and, where appropriate, adjunctive therapies such as metformin, particularly when agents with higher metabolic burden are used.

Another notable change is the recommendation for earlier evaluation of treatment response and more decisive action when outcomes are negative. The guidelines propose switching antipsychotics after just four weeks of inadequate response at therapeutic doses, a change from traditional approaches that often favoured longer treatment trials. In cases where two trials fail, clozapine is recommended without delay, which may come as a shock to many Australian clinicians. This shift reflects a move toward earlier, evidence-based escalation in care and addresses longstanding underuse of clozapine in Australia due to stringent titration guidelines and adherence protocols. The guidelines also promote the use of plasma monitoring to optimise dosing, and encourage shared decision making to support patient confidence and adherence, particularly when managing potential side effects. This is particularly important in the patient-led health model, as well as in regional and remote health settings. Together, these changes underscore a more dynamic approach to pharmacological care, where the medical team are encouraged to find the right approach tailored to each patient. 

Structural changes

For Australian clinicians, these practice shifts require both structural and cultural adjustments. Community mental health teams will need to prioritise early review and education timelines, while psychiatrists should adopt proactive medication strategies and consider LAIs earlier in the treatment course. General practitioners, who are often involved in physical health monitoring and team care, will play a crucial role in managing metabolic health and prescribing adjunctive therapies such as statins or antihypertensives to mitigate poor outcomes. Pharmacists, too, may increasingly contribute to treatment selection, medication education, and metabolic screening. Overall, we can see these guideline changes working in favour of a more collaborative healthcare approach. 

The INTEGRATE Guidelines provide clear guidance across the symptom spectrum, including positive, negative, depressive, and cognitive domains. For persistent positive symptoms, clinicians are advised to consider switching to agents with a different pharmacodynamic profile and to avoid reliance on outdated classifications such as “first-generation” versus “second-generation” antipsychotics. In cases of treatment resistance, more specialised interventions should be considered, including alternative pharmacological strategies or augmentation therapies. For ongoing negative, depressive, or cognitive symptoms, clinicians are encouraged to reassess for contributing factors, review current medication regimens, and explore both pharmacological and non-pharmacological options. Across all domains, the emphasis remains on personalised care, minimising side-effect burden, and supporting functional recovery through targeted, evidence-informed interventions.

Metabolic health is a central concern throughout treatment. Before initiating antipsychotic therapy, baseline investigations should include body mass index, waist circumference, blood pressure, glucose, lipids, prolactin, and ECG. Weekly monitoring of physical health markers is recommended for the first six weeks, with ongoing surveillance at three months and annually thereafter. Adjunctive treatments, such as metformin or GLP-1 receptor agonists, should be considered in cases of weight gain or metabolic syndrome, with escalation to specialist care for patients developing diabetes or cardiovascular risk.

Monitoring with intention 

The guidelines also provide practical advice on managing dopamine-related side effects. Parkinsonism, an uncommon but noted side effect, may be managed through dose reduction or switching to agents with lower D2 affinity, while akathisia may respond to other agents. In cases of symptomatic hyperprolactinaemia, switching to a dopamine partial agonist may be appropriate. The guidelines also highlight the importance of addressing substance use comorbidities through non-judgmental education and coordination with specialist services.

One of the most impressive features is a digital application accompanying the guideline, providing a user-friendly tool for real-time decision support. Essentially, clinicians can input symptom domains, current treatments, and side effects, and the platform suggests next steps aligned with guideline recommendations. It’s been a long time coming for long language models and the growth of large datasets to interpret with precision and nuance. While this is a welcome innovation, implementation across Australia will require investment in digital literacy (especially for an older generation of healthcare professionals), integration with electronic medical records (which are somewhat limited), and workforce training.

The Integration

The INTEGRATE Guidelines represent a significant step forward in the global approach to schizophrenia care, offering Australian clinicians a more structured, practical, and patient-centred framework for treatment. By prioritising early intervention, clear timelines for treatment evaluation, and strategies tailored to individual symptom domains with significantly greater accessibility; the guidelines aim to reduce delays in care, improve therapeutic outcomes, and enhance quality of life for people living with schizophrenia. Importantly, the emphasis on shared decision making, metabolic health, and personalised medication strategies reflects a more holistic view of treatment success, one that balances symptom control with long-term wellbeing. 

As services across Australia begin to incorporate these recommendations into everyday practice, the challenge ahead lies in ensuring systems are equipped to support timely monitoring, collaborative care, and access to the full range of therapeutic options. The INTEGRATE Guidelines provide the tools, now it is up to the clinical community to apply them with the urgency and precision this patient group deserves. 

Want to try the tools for yourself? Following the development of the treatment algorithm, the research group designed a web application using the Django framework. The application is accessible via both desktop and mobile devices. Users input current symptoms, medications, and side-effects and are presented with the relevant contents of the guidelines. Try this for yourself here: https://www.psymatik.com/accounts/login/?next=/guidelines/scz/

INTEGRATE: international guidelines for the algorithmic treatment of schizophrenia. McCutcheon, Robert AAgid, Ofer et al. The Lancet Psychiatry, Volume 12, Issue 5, 384 – 394