INTEGRATE指南：标准化精神分裂症药物治疗

大家好，欢迎收听精神药理学研究所播客。

Hi and welcome to the Psychopharmacology Institute podcast.

我是您的主持人理查德·西伯特医生。

I'm your host Doctor.

理查德·西伯特，这里是分享临床经验以帮助您及时了解领域动态的地方。

Richard Siebert and this is the place where we share clinical pearls to keep you updated in the field.

想象一下：你正在接诊一位22岁的大学生，他三个月前经历了首次精神病性发作。

Picture this: you're seeing a 22 year old college student who's experienced his first psychotic break three months ago.

他尝试过两种不同的抗精神病药物，但都没有产生足够的疗效。

He's tried two different antipsychotics but neither has produced adequate response.

他的父母在问接下来该怎么做，而你也在思考：是不是该考虑使用氯氮平了？

His parents are asking what comes next and you're wondering, is it time to consider clozapine?

好吧，这里有一件事值得考虑。

Well, here's something to consider.

为什么在治疗抵抗性精神分裂症中，氯氮平的使用在德国与美国、韩国与尼日利亚之间看起来如此不同？

Why does clozapine utilization for treatment resistant schizophrenia look so different in Germany compared to The United States or South Korea compared to Nigeria?

到目前为止，我们还没有一个清晰且被普遍接受的精神分裂症治疗路线图。

Well, to date, we haven't had a clear, universally accepted roadmap for the treatment of schizophrenia.

但这里有一些令人振奋的消息。

But here's some exciting news.

一项名为INTEGRATE的开创性国际精神分裂症指南已于2025年3月发表在《柳叶刀·精神病学》上。

A groundbreaking set of international schizophrenia guidelines called INTEGRATE was just published in The Lancet Psychiatry in March in 2025.

这些指南是来自30个国家的精神科医生通力合作的成果，覆盖了联合国所有地区。

These guidelines represent a collaborative effort from psychiatrists across 30 countries, covering all UN regions.

今天，我们很荣幸邀请到奥利弗·弗赖登雷希医生。

Today, we're fortunate to have Doctor.

他将讨论这种基于证据且实用的精神分裂症治疗算法，任何临床医生都能轻松遵循。

Oliver Freidenreich discussing this algorithmic approach to schizophrenia treatment, a framework that's both evidence based and practical enough for any clinician to follow.

这些指南的价值在于，它们在减少治疗中的不必要差异的同时，仍保留了以患者为中心所需的灵活性。

What makes these guidelines valuable is their focus on reducing unnecessary variability in care while maintaining the flexibility needed for patient centered treatment.

它们回应了关键问题，例如何时开始使用氯氮平、如何使用长效注射剂，甚至何时适合停药。

They address critical questions like when to start clozapine, how to use long acting injectables, and even when medication discontinuation might be appropriate.

对于我们的银牌和金牌会员，请不要忘记，您可以通过本快速解读获得CME学分。

For our Silver and Gold members, don't forget that you can earn CME credits for this Quick Take.

请查看节目笔记中的链接，了解有关我们的会员等级和您可使用的资源的更多信息。

Check out the link down in the show notes for more information on our membership tiers and the resources available to you.

现在，让我们听听医生的话。

And now let's listen to Doctor.

弗雷登赖希。

Fredenreich.

大家好，我是来自马萨诸塞州波士顿的问候。

Hi, and hello from Boston, Massachusetts.

我是奥利弗·弗雷登赖希，或称F医生。

Oliver Fredenreich or Doctor.

我代表精神药理学研究所。

F here for the Psychopharmacology Institute.

在今天的快速解读中，我简单地向大家介绍一项新发布的精神分裂症指南，该指南已于2025年3月发表在《柳叶刀·精神病学》上。

In this Quick Take today, I am basically simply going to make you aware that a new schizophrenia guideline was just published in The Lancet Psychiatry in March 2025.

该出版物的标题是《精神分裂症算法化治疗的整合国际指南》。

The title of the publication is Integrate International Guidelines for the Algorithmic Treatment of Schizophrenia.

这些指南由来自全球30个国家、涵盖所有联合国区域的大量精神科医生共同制定，是一次真正的国际合作。

These guidelines were developed by a large group of psychiatrists from 30 countries from all UN regions, so it is truly an international effort.

我需要声明一下，我是参与该指南制定过程的整合顾问小组成员之一，该过程包括一项伞状综述，用以开发一份调查问卷，随后通过全球受邀专家的反馈以及来自包括有亲身经历者在内的多个焦点小组的反馈达成共识。

I need to add a disclaimer that I was one of the members of the integrated advisory group that participated in the guideline process that, among other things, involved an umbrella review to develop a survey that was then used to achieve consensus among the invited experts all over the world with feedback along the way from various focus groups, including people with lived experience.

现在你可能会问：我们真的需要一份新的精神分裂症指南吗？

Now you should ask, did we really need a new schizophrenia guideline?

我认为答案是肯定的，因为许多现有指南要么已经过时，要么令人困惑。

And I think the answer is yes, since many guidelines are either outdated or confusing.

相比之下，INTEGRATE指南清晰地总结了当前任何国家都应视为高质量的精神分裂症诊疗标准，并以一种任何临床医生都能轻松遵循的算法形式呈现。

In contrast, the INTEGRATE guidelines represent a nice summary of what we would currently consider high quality schizophrenia care in any country, and they're presented in an algorithm that any clinician could easily follow.

拥有权威的国际共识指南，是减少精神分裂症诊疗差异的重要一步。

Having authoritative, international consensus guidelines represents an important step in reducing variability in schizophrenia care.

你可能会想：差异有什么问题吗？

And you may think variability, what's wrong with that?

在医学中，差异可能意味着护理质量低下。

Well, variability in medicine can be a sign of substandard care.

让我解释一下。

Let me explain.

例如，对于难治性精神分裂症，氯氮平的使用在德国、美国、韩国或尼日利亚之间，甚至在一个国家的各个地区之间，都没有理由存在差异。

For example, there is no reason why clozapine utilization for treatment resistant schizophrenia, for example, varies between Germany, The United States, South Korea, or Nigeria, or within regions in a country.

这仅仅是未能适当使用氯氮平的问题，因为无论患者居住在哪里，氯氮平都是难治性精神分裂症患者的首选治疗方案。

It is simply a problem of not using clozapine appropriately, as clozapine is the treatment of choice for any patient with treatment resistant schizophrenia, regardless of where the patient lives.

拥有一套普适的指南，至少是迈向所有精神分裂症患者最佳护理的第一步。

Having one guideline that is universal may be a good first step at least towards optimal schizophrenia care for all.

我认为这些指南的优势在于，它们具有动态性和灵活性，能够支持以患者为中心的护理，同时又不至于过于复杂，并为临床医生提供了切实可行的算法。

I would say the strength of these guidelines is that they are dynamic and flexible enough to allow for patient centered care, but that they are not too complex, and that they provide clinicians with an algorithm that they can actually follow.

如果每位临床医生都能遵循所提出的算法，我们就能显著提升所有精神分裂症患者的护理质量。

If every clinician just followed the proposed algorithm, we would greatly increase the quality of care across all patients with schizophrenia.

至于这些指南本身，它们基于几个基本假设。

As for the guidelines themselves, they make several basic assumptions.

共同决策至关重要，若患者未见改善应及早干预，并将药物副作用作为治疗决策的组成部分加以关注。

Shared decision making is key, acting early if a patient is not improving, and focusing on medication side effects as an integral part of treatment decisions.

关于具体建议，让我通过算法一来为您演示一位首发精神病患者的处理流程。

As for specific recommendations, let me just walk you through a first episode psychosis patient using the algorithm one.

如果没有偏好，建议从每天5毫克开始使用阿立哌唑作为首发精神病患者的初始抗精神病药物，若无反应则适当增加剂量。

If there is no preference, aripiprazole is suggested as an antipsychotic choice to begin treatment in a first episode patient starting with five milligrams per day, and then going up if there's no response appropriately.

第二，长效注射型抗精神病药对于预防复发至关重要，应常规且尽早提供，尤其重要的是，在初始治疗阶段确立耐受性和疗效后，应考虑将首发患者从口服剂型转换为长效注射剂型，而不仅仅是在依从性差时才考虑。

Two, long acting injectable antipsychotics are an important consideration for relapse prevention that ought to be offered routinely and early, including and this is important now including discussing switching your first episode patients from the oral to the long acting injectable formulation after the initial treatment phase, during which you establish tolerability and efficacy, and not just if there is poor adherence.

第三，如果患者状况良好，根据这些指南，在完成两年治疗且达到完全缓解后，可以讨论在六个月内逐步停用抗精神病药物。

Three, if your patient is doing well, there is the possibility in these guidelines of discussing, discontinuing, slowly discontinuing the antipsychotic over six months in first episode patients after two years of treatment if full remission was achieved.

第四，对于初始算法无效的患者，应及时给予氯氮平治疗，即在两种抗精神病药治疗无效达十二周时即可考虑使用。

And four, for those patients who do not do well with the initial algorithm, clozapine ought to be offered in a timely manner, meaning as early as say twelve weeks of ineffective treatment with two antipsychotics.

如果您遵循这些指南，包括常规使用二甲双胍等医学管理建议（尤其是在使用代谢风险较高的抗精神病药时），您将为首发精神分裂症患者提供卓越的照护。

If you followed these guidelines, including the medical management recommendations, like using metformin routinely if you're using a metabolically high risk antipsychotic, you would provide excellent care for your patient with first episode schizophrenia.

我鼓励您亲自在其他临床情境中尝试使用该算法。

I encourage you to try out the algorithm yourself for other clinical scenarios.

它确实非常有效。

It really works quite well.

但也存在一些不足之处。

There are some shortcomings.

这些指南仅限于精神药理学，这虽然是精神分裂症治疗的重要支柱，但若没有心理社会支持和康复，单独使用是不够的。

The guidelines are limited to psychopharmacology, which represents an important pillar of schizophrenia care, but it is insufficient treatment by itself without psychosocial supports and rehabilitation.

这些指南也无法评估新批准的非多巴胺能抗精神病药齐诺美林联合特拉比姆的作用，或GLP激动剂在体重管理中的作用。

The guidelines could also not weigh the role of the new non dopaminergic antipsychotic zenomeline plus trasbium, which was just approved in The United States, or the role of GLP agonists for weight management.

这就是我今天要强调的要点。

This is my bottom line for today.

目前，精神分裂症药物治疗已有了统一的、非国别特定的通用实用指南，这些指南在未来几年内将保持有效，并计划定期更新。

The field now has uniform, not country specific, universal practical guidelines for the pharmacological management of schizophrenia that are going to be current for at least a few years, with the plan to update them regularly.

我认为这些指南是确立精神分裂症患者良好药物治疗标准的重要一步。

I think these guidelines are an important step in establishing what good pharmacological treatment for patients with schizophrenia ought to look like.

我鼓励您查阅相关文献，查看总结这些指南的算法。

I encourage you to go to the publication and look at the algorithm that summarizes the guidelines.

将它们应用到您的临床实践中，并请务必、务必在您的诊所张贴这个算法。

Apply them to your own practice, and please, please, also post this algorithm in your clinic.

这是一个很好的教学工具，可以帮助您教育患者。

It's a great teaching tool to educate your patients.

如果您带教实习生、护士从业者或住院医师，这也非常适合作为教授如何为这一患者群体提供最佳护理的教材。

And also if you work with trainees, nurse practitioners, residents, also great to teach them how to provide optimal care for this patient group.

感谢您今天抽出时间并专注聆听。

Thank you for your time and attention today.

这是弗罗伊登赖希医生。

That was Doctor.

奥利弗·弗罗伊登赖希博士正在讨论新发布的INTEGRATE精神分裂症治疗指南，这是一项旨在标准化并改善这种复杂疾病患者护理的国际努力。

Oliver Freudenreich discussing the newly published INTEGRATE Guidelines for Schizophrenia Treatment, an international effort to standardize and improve care for patients with this challenging condition.

那么，让我们回到我之前提到的这位22岁患者。

So let's circle back to our 22 year old patient I mentioned earlier.

根据这些新指南，在为期12周的两次抗精神病药物治疗失败后，若无禁忌症，就应考虑使用氯氮平。

According to these new guidelines, after two unsuccessful antipsychotic trials over twelve weeks, assuming no contraindication, it's time to offer clozapine.

这是这些指南中最重要的转变之一，即在患者未见改善时尽早果断采取行动。

This is one of the most important shifts in these guidelines, acting early and decisively when patients aren't improving.

尽管我们许多人可能在两次抗精神病药物试验失败后就会提供氯氮平，但INTEGRATE指南建议从每天5毫克的阿立哌唑开始治疗，这种药物对首次精神病发作患者的代谢影响相对较小。

While many of us may already offer clozapine after two failed antipsychotic trials, the INTEGRATE guidelines recommend starting with aripiprazole at five milligrams daily, a medication with a relatively favorable metabolic profile in patients experiencing a first episode of psychosis.

作者还建议在治疗早期就考虑使用长效注射剂，而不仅仅针对依从性差的患者。

The authors also suggest considering long acting injectables early on in treatment, not just in those patients with poor adherence.

还要记住，这些指南还涉及了一个我们经常忽视的问题，那就是药物停用。

Also remember that the guidelines tackle something we don't discuss often enough, and that's medication discontinuation.

对于达到完全缓解并持续两年的患者，实际上建议在六个月内逐步减量抗精神病药物。

For patients who achieve full remission and maintain it for two years, there's actually a recommendation to discuss slowly tapering antipsychotics over six months.

这尊重了患者的自主权，并承认并非每个人都需要终身治疗。

This respects patients' autonomy and acknowledges that not everyone needs lifelong treatment.

另一个关键特点是整合医疗管理，例如在开具代谢风险较高的抗精神病药物时常规使用二甲双胍。

Another key feature is the integration of medical management, such as using metformin routinely when prescribing metabolically high risk antipsychotics.

当然，这些指南也并非没有局限性。

Now, these guidelines aren't without their limitations.

它们聚焦于精神药理学，而这只是精神分裂症患者综合护理的其中一个支柱。

They focus on psychopharmacology, which is, of course, just one pillar of comprehensive care for patients with schizophrenia.

它们也尚未涉及新获批的赞诺莫伦-托罗品组合以及GLP-1激动剂在体重管理中的新兴作用。

They also don't yet address the newly approved zanomolene trospium combination or the emerging role of GLP-one agonists for weight management.

我们最近几个月在播客中讨论过这两个话题，如果你还没听过，我建议你回去收听那些期节目。

We've discussed both of these topics in recent months in the podcast, and I'd encourage you to go back and listen to those episodes if you haven't already.

但这些指南确实提供了一个坚实的循证基础，使世界各地的任何临床医生都能遵循。

But what these guidelines do do is provide a solid evidence based foundation that any clinician nearly anywhere in the world, can follow.

这里的真正价值在于减少有害的差异，同时保留临床判断。

The real power here is reducing harmful variability while maintaining clinical judgment.

无论你是在柏林、波士顿、首尔还是拉各斯行医，这些指南都代表了高质量精神分裂症护理应有的样子。

These guidelines represent what high quality schizophrenia care should look like, regardless of whether you're practicing in Berlin, Boston, Seoul, or Lagos.

在结束之前，请记住，作为精神药理学研究所的白银或黄金会员，您可以通过登录账户并完成一份简短调查来获得0.5个CME学分。

Before we wrap up, remember that as silver or gold members of the Psychopharmacology Institute, you can earn 0.5 CME credits by logging into your account and answering a brief survey.

如果你今天喜欢收听，请通过在Apple播客上留下评价来帮助我们触达更多像你这样的临床医生。

If you enjoyed listening today, please help us reach more clinicians like yourself by leaving a review on Apple Podcasts.

今天就到这里了。

And that's all for today.

非常感谢您参与本次节目。

I'd like to thank you very much for joining me.

我是西伯医生。

This is Doctor.

理查德·西伯和我期待在下一期节目中与您再见。

Richard Sieber and I look forward to seeing you in our next episode.

再见。

Bye now.