Schizoaffective disorder
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
acute psychotic episode
start or review oral antipsychotic treatment
An acute psychotic episode may be the first psychotic episode, or it may occur in the setting of psychotic decompensation or resistance to antipsychotic medication.
The patient needs to be in a safe and predictable environment, and hospitalisation is often needed.
If the acute episode is the first presentation, the patient needs to be established on antipsychotic medication. Such patients are usually naïve to antipsychotic agents and should be started on low doses and the dose titrated according to response.[47]Kreyenbuhl J, Buchanan RW, Dickerson FB, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr Bull. 2010 Jan;36(1):94-103. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800150 http://www.ncbi.nlm.nih.gov/pubmed/19955388?tool=bestpractice.com Particular attention should be paid to adverse effects of the medication.
In a first acute psychotic episode, clozapine and olanzapine are not recommended. Clozapine may be recommended for patients with multiple episode disorder who fail at least two adequate trials of two different antipsychotic agents.
A trial of clozapine should last a minimum of 8 weeks.[47]Kreyenbuhl J, Buchanan RW, Dickerson FB, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr Bull. 2010 Jan;36(1):94-103. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800150 http://www.ncbi.nlm.nih.gov/pubmed/19955388?tool=bestpractice.com
Routine checking of serum clozapine levels is not recommended; however, for clozapine non-responders it is recommended that the dose be increased, adverse effects permitting, for a target level >350 nanograms/mL.
Clozapine is available only under a restricted access scheme in a number of countries. White blood cell count and absolute neutrophil count should be tested periodically, owing to the risk of potentially life-threatening agranulocytosis.
If the acute episode is due to psychotic decompensation or to antipsychotic resistance, the medication dose often needs to be increased or a new antipsychotic medication started. If the patient has previously responded to a specific agent and the acute episode is a result of non-compliance, treatment can be titrated to the previously effective dose.
Other antipsychotic medications may be available depending on location.
Primary options
paliperidone: 6 mg orally once daily initially, increase gradually according to response, maximum 12 mg/day
OR
ziprasidone: 20 mg orally twice daily initially, increase gradually according to response, maximum 160 mg/day
OR
aripiprazole: 10-15 mg orally once daily initially, increase gradually according to response, maximum 30 mg/day
OR
risperidone: 1 mg orally twice daily initially, increase gradually according to response, maximum 16 mg/day (usual range 4-8 mg/day), doses >6 mg/day increase risk of extrapyramidal effects
OR
quetiapine: 25 mg orally (immediate release) twice daily initially, increase gradually according to response, maximum 800 mg/day; 300 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 800 mg/day
OR
iloperidone: 1 mg orally twice daily initially, increase gradually according to response, maximum 24 mg/day
OR
asenapine: 5 mg sublingually twice daily initially, increase gradually according to response, maximum 20 mg/day
OR
lurasidone: 40 mg orally once daily initially, increase gradually according to response, maximum 160 mg/day
OR
brexpiprazole: 1 mg orally once daily for 4 days, then 2 mg once daily for 3 days, then 4 mg once daily, maximum 4 mg/day
OR
cariprazine: 1.5 mg orally once daily on day 1, then 3 mg once daily on day 2, then increase gradually according to response, maximum 6 mg/day
OR
lumateperone: 42 mg orally once daily
Secondary options
olanzapine: 5-10 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day
More olanzapineOlanzapine is not recommended in patients with a first acute psychotic episode.
Olanzapine is available in an oral combination formulation with samidorphan in some countries. Samidorphan is a mu-receptor opioid antagonist that may help mitigate weight gain associated with olanzapine.
OR
clozapine: 12.5 mg orally once or twice daily initially, increase gradually according to response, maximum 900 mg/day
More clozapineClozapine is not recommended in patients with a first acute psychotic episode.
Tertiary options
haloperidol: 0.5 to 5 mg orally two to three times daily initially, increase gradually according to response, usual dose 5-20 mg/day, maximum 100 mg/day
OR
fluphenazine: 2.5 to 10 mg/day orally given in 3-4 divided doses initially, increase gradually according to response, maximum 40 mg/day
OR
trifluoperazine: 1-2 mg orally twice daily initially, increase gradually according to response, maximum 40 mg/day
oral benzodiazepine
Additional treatment recommended for SOME patients in selected patient group
If the patient is severely agitated or distressed, consider an oral benzodiazepine, if tolerated.[72]Taylor DM, Barnes TRE, Young AH. The Maudsley prescribing guidelines in psychiatry. 14th ed. Chichester: Wiley-Blackwell; 2021.
Primary options
lorazepam: 2 mg orally every 30-60 minutes when required
rapid tranquilisation
Additional treatment recommended for SOME patients in selected patient group
If the patient becomes aggressive or violent, involve a senior colleague and seek advice from the mental health team. The patient may use aggression as a defence, which can increase the risk of harm to themselves and others.
Parenteral medication (rapid tranquillisation) may be used if de-escalation techniques and oral benzodiazepines have failed, and only if absolutely necessary after weighing up the risks and benefits. Always inform the patient that medication is going to be administered and give them the opportunity to accept oral medication voluntarily. Patients at high risk of sedation may be transferred to a setting where ventilatory support is available.
Protocols for rapid tranquilisation vary. The UK National Institute for Health and Care Excellence (NICE) recommends using lorazepam alone or haloperidol combined with promethazine.[33]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10
NICE recommends against the use of intramuscular haloperidol combined with intramuscular promethazine if the patient has any evidence of cardiovascular disease (including a prolonged QT interval) or if no ECG has been carried out. Intramuscular lorazepam can be used in this patient group instead.[33]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10
NICE recommends monitoring side effects, pulse, blood pressure, respiratory rate, temperature, level of hydration, and level of consciousness at least every hour until there are no further concerns. Consider monitoring oxygen saturation using pulse oximetry; check your local protocol. Monitor the patient every 15 minutes if the maximum dose has been exceeded or they: appear to be asleep or sedated, have taken illicit drugs or alcohol, have a pre-existing medical condition, or have experienced harm as a result of a restrictive intervention.[33]National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community settings. May 2015 [internet publication]. https://www.nice.org.uk/guidance/ng10
Primary options
lorazepam: consult specialist for guidance on intramuscular dose
Secondary options
promethazine: consult specialist for guidance on intramuscular dose
and
haloperidol: consult specialist for guidance on intramuscular dose
electroconvulsive therapy
Additional treatment recommended for SOME patients in selected patient group
Evidence suggests electroconvulsive therapy (ECT) is beneficial in patients with schizophrenia, particularly in patients with catatonia or significant suicide risk.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021. https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841 ECT is also effective for refractory major mood symptoms and may be considered for treatment-refractory schizoaffective disorder in conjunction with antipsychotic therapy.
There are no clear studies demonstrating superiority of specific antipsychotics as augmentation with ECT. In studies of patients with schizophrenia, symptoms and rates of remission improved with clozapine plus ECT treatment compared with clozapine alone.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021. https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841 [68]Petrides G, Malur C, Braga RJ, et al. Electroconvulsive therapy augmentation in clozapine-resistant schizophrenia: a prospective, randomized study. Am J Psychiatry. 2015 Jan;172(1):52-8. https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2014.13060787 http://www.ncbi.nlm.nih.gov/pubmed/25157964?tool=bestpractice.com Some evidence suggests antipsychotics other than clozapine may also be beneficial.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021. https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841
Other medications may need to be adjusted before starting ECT as some (e.g., benzodiazepines, lithium) can affect the treatment.[69]Zolezzi M. Medication management during electroconvulsant therapy. Neuropsychiatr Dis Treat. 2016 Apr 19;12:931-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4844444 http://www.ncbi.nlm.nih.gov/pubmed/27143894?tool=bestpractice.com Consult a specialist for guidance.
multiple-episode disorder
atypical antipsychotic
The first line of treatment should be an atypical antipsychotic agent other than clozapine.[47]Kreyenbuhl J, Buchanan RW, Dickerson FB, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr Bull. 2010 Jan;36(1):94-103. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800150 http://www.ncbi.nlm.nih.gov/pubmed/19955388?tool=bestpractice.com The benefits of these agents over older antipsychotics, in terms of decreased risk for extrapyramidal adverse effects and tardive dyskinesia, need to be balanced on an individual basis against the increased risk for weight gain and metabolic syndrome, which is especially seen with olanzapine.[41]Peuskens J. Good medical practice in antipsychotic pharmacotherapy. Int Clin Psychopharmacol. 1998 Mar;13(suppl 3):S35-41. http://www.ncbi.nlm.nih.gov/pubmed/9690969?tool=bestpractice.com
For patients with established illness, information on previous treatments, dose, duration of treatment, and response to each particular agent should be gathered.
Patients should be given the minimum dose that controls their symptoms, with adequate follow-up for possible medication adjustments and monitoring of adverse effects. Medication should be continued indefinitely but titrated, switched to another agent, or discontinued if adverse effects are intolerable. There is no correlation between the drug dose and therapeutic effect, but the risk of extrapyramidal signs (e.g., akathisia, parkinsonism, and dystonia) increases with dose.
In people with treatment-responsive, multi-episode schizoaffective disorder who are experiencing an acute exacerbation, the minimum recommended length of treatment trial is 2 weeks, with an upper limit of 6 weeks to observe optimal response.
For maintenance therapy, continuous treatment is recommended. Intermittent, targeted treatment may increase the risk for symptom exacerbation and relapse, and it is not recommended.[47]Kreyenbuhl J, Buchanan RW, Dickerson FB, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr Bull. 2010 Jan;36(1):94-103. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800150 http://www.ncbi.nlm.nih.gov/pubmed/19955388?tool=bestpractice.com
If the first agent that is used fails, a trial with a different atypical antipsychotic agent (other than clozapine) should be done.
Other antipsychotic medications may be available depending on location.
Primary options
paliperidone: 6 mg orally once daily initially, increase gradually according to response, maximum 12 mg/day
OR
olanzapine: 5-10 mg orally once daily initially, increase gradually according to response, maximum 20 mg/day
More olanzapineOlanzapine is available in an oral combination formulation with samidorphan in some countries. Samidorphan is a mu-receptor opioid antagonist that may help mitigate weight gain associated with olanzapine.
OR
ziprasidone: 20 mg orally twice daily initially, increase gradually according to response, maximum 160 mg/day
OR
aripiprazole: 10-15 mg orally once daily initially, increase gradually according to response, maximum 30 mg/day
OR
risperidone: 1 mg orally twice daily initially, increase gradually according to response, maximum 16 mg/day (usual range 4-8 mg/day), doses >6 mg/day increase risk of extrapyramidal effects
OR
quetiapine: 25 mg orally (immediate release) twice daily initially, increase gradually according to response, maximum 800 mg/day; 300 mg orally (extended-release) once daily initially, increase gradually according to response, maximum 800 mg/day
OR
iloperidone: 1 mg orally twice daily initially, increase gradually according to response, maximum 24 mg/day
OR
asenapine: 5 mg sublingually twice daily initially, increase gradually according to response, maximum 20 mg/day
OR
lurasidone: 40 mg orally once daily initially, increase gradually according to response, maximum 160 mg/day
OR
brexpiprazole: 1 mg orally once daily for 4 days, then 2 mg once daily for 3 days, then 4 mg once daily, maximum 4 mg/day
OR
cariprazine: 1.5 mg orally once daily on day 1, then 3 mg once daily on day 2, then increase gradually according to response, maximum 6 mg/day
OR
lumateperone: 42 mg orally once daily
psychosocial interventions
Treatment recommended for ALL patients in selected patient group
Psychosocial interventions are key components of long-term management. The Patient Outcomes Research Team (PORT) guidelines recommend the following psychosocial interventions: assertive community treatment, supported employment, skills training, cognitive behavioural therapy (CBT), token economy interventions, and family-based services.[47]Kreyenbuhl J, Buchanan RW, Dickerson FB, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr Bull. 2010 Jan;36(1):94-103.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800150
http://www.ncbi.nlm.nih.gov/pubmed/19955388?tool=bestpractice.com
[ 
]
In people with chronic mental illnesses, how do life skills programs affect outcomes?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.564/fullShow me the answer CBT for psychosis (CBTp), cognitive remediation, psychoeducation, and supportive therapy have been shown to be effective and should be started early in treatment.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021.
https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841
[47]Kreyenbuhl J, Buchanan RW, Dickerson FB, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr Bull. 2010 Jan;36(1):94-103.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800150
http://www.ncbi.nlm.nih.gov/pubmed/19955388?tool=bestpractice.com
[56]Anaya C, Martinez Aran A, Ayuso-Mateos JL, et al. A systematic review of cognitive remediation for schizo-affective and affective disorders. J Affect Disord. 2012 Dec 15;142(1-3):13-21.
http://www.ncbi.nlm.nih.gov/pubmed/22840620?tool=bestpractice.com
Other interventions that may be beneficial include supportive psychotherapy, intensive case management, and cognitive enhancement treatment.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021.
https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841
CBTp is more efficacious in decreasing positive symptoms, and social skill training is efficacious in decreasing negative symptoms.[57]Turner DT, van der Gaag M, Karyotaki E, et al. Psychological interventions for psychosis: a meta-analysis of comparative outcome studies. Am J Psychiatry. 2014 May;171(5):523-38. http://www.ncbi.nlm.nih.gov/pubmed/24525715?tool=bestpractice.com [58]Jauhar S, McKenna PJ, Radua J, et al. Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. Br J Psychiatry. 2014 Jan;204(1):20-9. http://www.ncbi.nlm.nih.gov/pubmed/24385461?tool=bestpractice.com
A minimum duration of 16 CBTp sessions is recommended.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021. https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841 [59]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178 However, studies suggest that treatment benefits may no longer be significant after 6 months.
Monitor for depressive symptoms and risk factors for suicide. Case management should be implemented early in the illness process.
Family issues need to be addressed early because interventions are useful in relapse prevention.
general health maintenance
Treatment recommended for ALL patients in selected patient group
Schizoaffective disorder is associated with increased frequency of medical illnesses and with a 15- to 20-year reduction in life expectancy. Managing the adverse effects of medications is crucial because many of these agents further increase the risk of medical illness. Health maintenance is, therefore, targeted to these adverse effects.
Possible adverse effects include neurological adverse effects, metabolic abnormalities (weight gain, blood glucose levels), hyperprolactinaemia, cardiac abnormalities, agranulocytosis, postural hypotension, and anticholinergic adverse effects.
anxiolytic
Additional treatment recommended for SOME patients in selected patient group
Patients with symptoms of anxiety may benefit from the addition of an anxiolytic.[53]Barnes TR, Drake R, Paton C, et al. Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2020 Jan;34(1):3-78. https://journals.sagepub.com/doi/10.1177/0269881119889296 http://www.ncbi.nlm.nih.gov/pubmed/31829775?tool=bestpractice.com
Studies have failed to demonstrate that buspirone is consistently effective against panic attacks.[54]Cottraux J, Note ID, Cungi C, et al. A controlled study of cognitive behaviour therapy with buspirone or placebo in panic disorder with agoraphobia. Br J Psychiatry. 1995 Nov;167(5):635-41. http://www.ncbi.nlm.nih.gov/pubmed/8564320?tool=bestpractice.com [55]Bouvard M, Mollard E, Guerin J, et al. Study and course of the psychological profile in 77 patients expressing panic disorder with agoraphobia after cognitive behaviour therapy with or without buspirone. Psychother Psychosom. 1997;66(1):27-32. http://www.ncbi.nlm.nih.gov/pubmed/8996712?tool=bestpractice.com
Primary options
alprazolam: 0.25 mg orally (immediate-release) three times daily initially, increase gradually according to response, maximum 4 mg/day
OR
clonazepam: 0.25 mg orally twice daily initially, increase gradually according to response, maximum 4 mg/day
OR
diazepam: 2-10 mg orally two to four times daily
OR
buspirone: 7.5 mg orally twice daily initially, increase gradually according to response, maximum 60 mg/day
lithium
Additional treatment recommended for SOME patients in selected patient group
For patients who do not achieve a satisfactory treatment response with antipsychotics, augmentation with lithium may improve the clinical response.[51]Leucht S, Helfer B, Dold M, et al. Lithium for schizophrenia. Cochrane Database Syst Rev. 2015 Oct 28;2015(10):CD003834. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003834.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/26509923?tool=bestpractice.com
Primary options
lithium: 300 mg orally (regular-release) two to three times daily initially, increase gradually according to response and serum drug level, maximum 2400 mg/day
clozapine for treatment failure of 2 preferred atypical antipsychotic agents
Clozapine may be recommended for patients with multiple episode disorder who fail at least two adequate trials of two different antipsychotic agents. A trial of clozapine should last a minimum of 8 weeks.[47]Kreyenbuhl J, Buchanan RW, Dickerson FB, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr Bull. 2010 Jan;36(1):94-103. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800150 http://www.ncbi.nlm.nih.gov/pubmed/19955388?tool=bestpractice.com
Routine checking of serum clozapine levels is not recommended; however, for clozapine non-responders it is recommended that the dose be increased, adverse effects permitting, for a target level >350 nanograms/mL.
Clozapine is available only under a restricted access scheme in a number of countries. White blood cell count and absolute neutrophil count should be tested periodically, owing to the risk of potentially life-threatening agranulocytosis.
Primary options
clozapine: 12.5 mg orally once or twice daily initially, increase gradually according to response, maximum 900 mg/day
psychosocial interventions
Treatment recommended for ALL patients in selected patient group
Psychosocial interventions are key components of long-term management. The Patient Outcomes Research Team (PORT) guidelines recommend the following psychosocial interventions: assertive community treatment, supported employment, skills training, cognitive behavioural therapy (CBT), token economy interventions, and family-based services.[47]Kreyenbuhl J, Buchanan RW, Dickerson FB, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr Bull. 2010 Jan;36(1):94-103.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800150
http://www.ncbi.nlm.nih.gov/pubmed/19955388?tool=bestpractice.com
[ ]
In people with chronic mental illnesses, how do life skills programs affect outcomes?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.564/fullShow me the answer CBT for psychosis (CBTp), cognitive remediation, psychoeducation, and supportive therapy have been shown to be effective and should be started early in treatment.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021.
https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841
[47]Kreyenbuhl J, Buchanan RW, Dickerson FB, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr Bull. 2010 Jan;36(1):94-103.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800150
http://www.ncbi.nlm.nih.gov/pubmed/19955388?tool=bestpractice.com
[56]Anaya C, Martinez Aran A, Ayuso-Mateos JL, et al. A systematic review of cognitive remediation for schizo-affective and affective disorders. J Affect Disord. 2012 Dec 15;142(1-3):13-21.
http://www.ncbi.nlm.nih.gov/pubmed/22840620?tool=bestpractice.com
Other interventions that may be beneficial include supportive psychotherapy, intensive case management, and cognitive enhancement treatment.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021.
https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841
CBTp is more efficacious in decreasing positive symptoms, and social skill training is efficacious in decreasing negative symptoms.[57]Turner DT, van der Gaag M, Karyotaki E, et al. Psychological interventions for psychosis: a meta-analysis of comparative outcome studies. Am J Psychiatry. 2014 May;171(5):523-38. http://www.ncbi.nlm.nih.gov/pubmed/24525715?tool=bestpractice.com [58]Jauhar S, McKenna PJ, Radua J, et al. Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. Br J Psychiatry. 2014 Jan;204(1):20-9. http://www.ncbi.nlm.nih.gov/pubmed/24385461?tool=bestpractice.com
A minimum duration of 16 CBTp sessions is recommended.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021. https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841 [59]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178 However, studies suggest that treatment benefits may no longer be significant after 6 months.
Monitor for depressive symptoms and risk factors for suicide. Case management should be implemented early in the illness process.
Family issues need to be addressed early because interventions are useful in relapse prevention.
general health maintenance
Treatment recommended for ALL patients in selected patient group
Schizoaffective disorder is associated with increased frequency of medical illnesses and with a 15- to 20-year reduction in life expectancy. Managing the adverse effects of medications is crucial because many of these agents further increase the risk of medical illness. Health maintenance is, therefore, targeted to these adverse effects.
Possible adverse effects include neurological adverse effects, metabolic abnormalities (weight gain, blood glucose levels), hyperprolactinaemia, cardiac abnormalities, agranulocytosis, postural hypotension, and anticholinergic adverse effects.
anxiolytic
Additional treatment recommended for SOME patients in selected patient group
Patients with symptoms of anxiety may benefit from the addition of an anxiolytic.[53]Barnes TR, Drake R, Paton C, et al. Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2020 Jan;34(1):3-78. https://journals.sagepub.com/doi/10.1177/0269881119889296 http://www.ncbi.nlm.nih.gov/pubmed/31829775?tool=bestpractice.com
Studies have failed to demonstrate that buspirone is consistently effective against panic attacks.[54]Cottraux J, Note ID, Cungi C, et al. A controlled study of cognitive behaviour therapy with buspirone or placebo in panic disorder with agoraphobia. Br J Psychiatry. 1995 Nov;167(5):635-41. http://www.ncbi.nlm.nih.gov/pubmed/8564320?tool=bestpractice.com [55]Bouvard M, Mollard E, Guerin J, et al. Study and course of the psychological profile in 77 patients expressing panic disorder with agoraphobia after cognitive behaviour therapy with or without buspirone. Psychother Psychosom. 1997;66(1):27-32. http://www.ncbi.nlm.nih.gov/pubmed/8996712?tool=bestpractice.com
Primary options
alprazolam: 0.25 mg orally (immediate-release) three times daily initially, increase gradually according to response, maximum 4 mg/day
OR
clonazepam: 0.25 mg orally twice daily initially, increase gradually according to response, maximum 4 mg/day
OR
diazepam: 2-10 mg orally two to four times daily
OR
buspirone: 7.5 mg orally twice daily initially, increase gradually according to response, maximum 60 mg/day
lithium
Additional treatment recommended for SOME patients in selected patient group
For patients who do not achieve a satisfactory treatment response with antipsychotics, augmentation with lithium may improve the clinical response.[51]Leucht S, Helfer B, Dold M, et al. Lithium for schizophrenia. Cochrane Database Syst Rev. 2015 Oct 28;2015(10):CD003834. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003834.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/26509923?tool=bestpractice.com
Primary options
lithium: 300 mg orally (regular-release) two to three times daily initially, increase gradually according to response and serum drug level, maximum 2400 mg/day
typical antipsychotic
The efficacy of these medications is well established, but they are not generally recommended as initial treatment because they carry a higher likelihood of tardive dyskinesia and worsening of negative symptoms.
Haloperidol use should be limited to situations when no other antipsychotic medications with fewer extrapyramidal adverse effects can be used.
In pregnancy, typical antipsychotics appear less harmful than atypical antipsychotics in terms of risk of gestational metabolic complications, increased weight for gestational age, and birth weight.
Medication should be continued indefinitely, but should be titrated, switched to another agent, or discontinued if adverse effects are intolerable.
Other antipsychotic medications may be available depending on location.
Primary options
haloperidol: 0.5 to 5 mg orally two to three times daily initially, increase gradually according to response, usual dose 5-20 mg/day, maximum 100 mg/day
OR
fluphenazine: 2.5 to 10 mg/day orally given in 3-4 divided doses initially, increase gradually according to response, maximum 40 mg/day
OR
trifluoperazine: 1-2 mg orally twice daily initially, increase gradually according to response, maximum 40 mg/day
psychosocial interventions
Treatment recommended for ALL patients in selected patient group
Psychosocial interventions are key components of long-term management. The Patient Outcomes Research Team (PORT) guidelines recommend the following psychosocial interventions: assertive community treatment, supported employment, skills training, cognitive behavioural therapy (CBT), token economy interventions, and family-based services.[47]Kreyenbuhl J, Buchanan RW, Dickerson FB, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr Bull. 2010 Jan;36(1):94-103.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800150
http://www.ncbi.nlm.nih.gov/pubmed/19955388?tool=bestpractice.com
[ ]
In people with chronic mental illnesses, how do life skills programs affect outcomes?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.564/fullShow me the answer CBT for psychosis (CBTp), cognitive remediation, psychoeducation, and supportive therapy have been shown to be effective and should be started early in treatment.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021.
https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841
[47]Kreyenbuhl J, Buchanan RW, Dickerson FB, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr Bull. 2010 Jan;36(1):94-103.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800150
http://www.ncbi.nlm.nih.gov/pubmed/19955388?tool=bestpractice.com
[56]Anaya C, Martinez Aran A, Ayuso-Mateos JL, et al. A systematic review of cognitive remediation for schizo-affective and affective disorders. J Affect Disord. 2012 Dec 15;142(1-3):13-21.
http://www.ncbi.nlm.nih.gov/pubmed/22840620?tool=bestpractice.com
Other interventions that may be beneficial include supportive psychotherapy, intensive case management, and cognitive enhancement treatment.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021.
https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841
CBTp is more efficacious in decreasing positive symptoms, and social skill training is efficacious in decreasing negative symptoms.[57]Turner DT, van der Gaag M, Karyotaki E, et al. Psychological interventions for psychosis: a meta-analysis of comparative outcome studies. Am J Psychiatry. 2014 May;171(5):523-38. http://www.ncbi.nlm.nih.gov/pubmed/24525715?tool=bestpractice.com [58]Jauhar S, McKenna PJ, Radua J, et al. Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. Br J Psychiatry. 2014 Jan;204(1):20-9. http://www.ncbi.nlm.nih.gov/pubmed/24385461?tool=bestpractice.com
A minimum duration of 16 CBTp sessions is recommended.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021. https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841 [59]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178 However, studies suggest that treatment benefits may no longer be significant after 6 months.
Monitor for depressive symptoms and risk factors for suicide. Case management should be implemented early in the illness process.
Family issues need to be addressed early because interventions are useful in relapse prevention.
general health maintenance
Treatment recommended for ALL patients in selected patient group
Schizoaffective disorder is associated with increased frequency of medical illnesses and with a 15- to 20-year reduction in life expectancy. Managing the adverse effects of medications is crucial because many of these agents further increase the risk of medical illness. Health maintenance is, therefore, targeted to these adverse effects.
Possible adverse effects include neurological adverse effects, metabolic abnormalities (weight gain, blood glucose levels), hyperprolactinaemia, cardiac abnormalities, agranulocytosis, postural hypotension, and anticholinergic adverse effects.
anxiolytic
Additional treatment recommended for SOME patients in selected patient group
Patients with symptoms of anxiety may benefit from the addition of an anxiolytic.[53]Barnes TR, Drake R, Paton C, et al. Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2020 Jan;34(1):3-78. https://journals.sagepub.com/doi/10.1177/0269881119889296 http://www.ncbi.nlm.nih.gov/pubmed/31829775?tool=bestpractice.com
Studies have failed to demonstrate that buspirone is consistently effective against panic attacks.[54]Cottraux J, Note ID, Cungi C, et al. A controlled study of cognitive behaviour therapy with buspirone or placebo in panic disorder with agoraphobia. Br J Psychiatry. 1995 Nov;167(5):635-41. http://www.ncbi.nlm.nih.gov/pubmed/8564320?tool=bestpractice.com [55]Bouvard M, Mollard E, Guerin J, et al. Study and course of the psychological profile in 77 patients expressing panic disorder with agoraphobia after cognitive behaviour therapy with or without buspirone. Psychother Psychosom. 1997;66(1):27-32. http://www.ncbi.nlm.nih.gov/pubmed/8996712?tool=bestpractice.com
Primary options
alprazolam: 0.25 mg orally (immediate-release) three times daily initially, increase gradually according to response, maximum 4 mg/day
OR
clonazepam: 0.25 mg orally twice daily initially, increase gradually according to response, maximum 4 mg/day
OR
diazepam: 2-10 mg orally two to four times daily
OR
buspirone: 7.5 mg orally twice daily initially, increase gradually according to response, maximum 60 mg/day
lithium
Additional treatment recommended for SOME patients in selected patient group
For patients who do not achieve a satisfactory treatment response, augmentation with lithium may improve the clinical response.[51]Leucht S, Helfer B, Dold M, et al. Lithium for schizophrenia. Cochrane Database Syst Rev. 2015 Oct 28;2015(10):CD003834. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003834.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/26509923?tool=bestpractice.com
Primary options
lithium: 300 mg orally (regular-release) two to three times daily initially, increase gradually according to response and serum drug level, maximum 2400 mg/day
long-acting intramuscular antipsychotic
In patients with an extensive history of non-compliance, a long-acting intramuscular antipsychotic should be considered. Oral efficacy and tolerability should be established first before switching to an long-acting intramuscular antipsychotic.[43]Sajatovic M, Ross R, Legacy SN, et al. Initiating/maintaining long-acting injectable antipsychotics in schizophrenia/schizoaffective or bipolar disorder: expert consensus survey part 2. Neuropsychiatr Dis Treat. 2018 Jun 8;14:1475-92. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5997122 http://www.ncbi.nlm.nih.gov/pubmed/29922063?tool=bestpractice.com
Depot fluphenazine may have similar efficacy as oral fluphenazine in treating patients with schizophrenia.[73]Zhornitsky S, Stip E. Oral versus long-acting injectable antipsychotics in the treatment of schizophrenia and special populations at risk for treatment nonadherence: a systematic review. Schizophr Res Treatment. 2012;2012:407171. https://www.hindawi.com/journals/schizort/2012/407171 http://www.ncbi.nlm.nih.gov/pubmed/22966436?tool=bestpractice.com
Primary options
risperidone: 25-50 mg intramuscularly (extended-release suspension) every 2 weeks
OR
paliperidone: 234 mg intramuscularly (extended-release suspension) as a single dose initially, followed by 156 mg one week later, then 117 mg once monthly thereafter
OR
olanzapine: 150-300 mg intramuscularly (extended-release suspension) every 2 weeks, or 405 mg every 2 weeks
OR
aripiprazole: 300-400 mg intramuscularly once monthly
More aripiprazoleDose refers to Abilfy Maintena® brand and not the aripiprazole lauroxil formulation.
Secondary options
haloperidol decanoate: dose depends on previous oral haloperidol dose; consult specialist for guidance
OR
fluphenazine decanoate: 12.5 to 25 mg intramuscularly once monthly or at longer intervals depending on response and tolerance
psychosocial interventions
Treatment recommended for ALL patients in selected patient group
Psychosocial interventions are key components of long-term management. The Patient Outcomes Research Team (PORT) guidelines recommend the following psychosocial interventions: assertive community treatment, supported employment, skills training, cognitive behavioural therapy (CBT), token economy interventions, and family-based services.[47]Kreyenbuhl J, Buchanan RW, Dickerson FB, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr Bull. 2010 Jan;36(1):94-103.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800150
http://www.ncbi.nlm.nih.gov/pubmed/19955388?tool=bestpractice.com
[ ]
In people with chronic mental illnesses, how do life skills programs affect outcomes?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.564/fullShow me the answer CBT for psychosis (CBTp), cognitive remediation, psychoeducation, and supportive therapy have been shown to be effective and should be started early in treatment.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021.
https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841
[47]Kreyenbuhl J, Buchanan RW, Dickerson FB, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr Bull. 2010 Jan;36(1):94-103.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800150
http://www.ncbi.nlm.nih.gov/pubmed/19955388?tool=bestpractice.com
[56]Anaya C, Martinez Aran A, Ayuso-Mateos JL, et al. A systematic review of cognitive remediation for schizo-affective and affective disorders. J Affect Disord. 2012 Dec 15;142(1-3):13-21.
http://www.ncbi.nlm.nih.gov/pubmed/22840620?tool=bestpractice.com
Other interventions that may be beneficial include supportive psychotherapy, intensive case management, and cognitive enhancement treatment.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021.
https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841
CBTp is more efficacious in decreasing positive symptoms, and social skill training is efficacious in decreasing negative symptoms.[57]Turner DT, van der Gaag M, Karyotaki E, et al. Psychological interventions for psychosis: a meta-analysis of comparative outcome studies. Am J Psychiatry. 2014 May;171(5):523-38. http://www.ncbi.nlm.nih.gov/pubmed/24525715?tool=bestpractice.com [58]Jauhar S, McKenna PJ, Radua J, et al. Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. Br J Psychiatry. 2014 Jan;204(1):20-9. http://www.ncbi.nlm.nih.gov/pubmed/24385461?tool=bestpractice.com
A minimum duration of 16 CBTp sessions is recommended.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021. https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841 [59]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178 However, studies suggest that treatment benefits may no longer be significant after 6 months.
Monitor for depressive symptoms and risk factors for suicide. Case management should be implemented early in the illness process.
Family issues need to be addressed early because interventions are useful in relapse prevention.
general health maintenance
Treatment recommended for ALL patients in selected patient group
Schizoaffective disorder is associated with increased frequency of medical illnesses and with a 15- to 20-year reduction in life expectancy. Managing the adverse effects of medications is crucial because many of these agents further increase the risk of medical illness. Health maintenance is, therefore, targeted to these adverse effects.
Possible adverse effects include neurological adverse effects, metabolic abnormalities (weight gain, blood glucose levels), hyperprolactinaemia, cardiac abnormalities, agranulocytosis, postural hypotension, and anticholinergic adverse effects.
anxiolytic
Additional treatment recommended for SOME patients in selected patient group
Patients with symptoms of anxiety may benefit from the addition of an anxiolytic.[53]Barnes TR, Drake R, Paton C, et al. Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2020 Jan;34(1):3-78. https://journals.sagepub.com/doi/10.1177/0269881119889296 http://www.ncbi.nlm.nih.gov/pubmed/31829775?tool=bestpractice.com
Studies have failed to demonstrate that buspirone is consistently effective against panic attacks.[54]Cottraux J, Note ID, Cungi C, et al. A controlled study of cognitive behaviour therapy with buspirone or placebo in panic disorder with agoraphobia. Br J Psychiatry. 1995 Nov;167(5):635-41. http://www.ncbi.nlm.nih.gov/pubmed/8564320?tool=bestpractice.com [55]Bouvard M, Mollard E, Guerin J, et al. Study and course of the psychological profile in 77 patients expressing panic disorder with agoraphobia after cognitive behaviour therapy with or without buspirone. Psychother Psychosom. 1997;66(1):27-32. http://www.ncbi.nlm.nih.gov/pubmed/8996712?tool=bestpractice.com
Primary options
alprazolam: 0.25 mg orally (immediate-release) three times daily initially, increase gradually according to response, maximum 4 mg/day
OR
clonazepam: 0.25 mg orally twice daily initially, increase gradually according to response, maximum 4 mg/day
OR
diazepam: 2-10 mg orally two to four times daily
OR
buspirone: 7.5 mg orally twice daily initially, increase gradually according to response, maximum 60 mg/day
lithium
Additional treatment recommended for SOME patients in selected patient group
For patients who do not achieve a satisfactory treatment response with antipsychotics, augmentation with lithium may improve the clinical response.[51]Leucht S, Helfer B, Dold M, et al. Lithium for schizophrenia. Cochrane Database Syst Rev. 2015 Oct 28;2015(10):CD003834. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003834.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/26509923?tool=bestpractice.com
Primary options
lithium: 300 mg orally (regular-release) two to three times daily initially, increase gradually according to response and serum drug level, maximum 2400 mg/day
electroconvulsive therapy
Evidence suggests electroconvulsive therapy (ECT) is beneficial in patients with schizophrenia, particularly in patients with catatonia or significant suicide risk.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021. https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841 ECT is also effective for refractory major mood symptoms and may be considered for treatment-refractory schizoaffective disorder in conjunction with antipsychotic therapy.
clozapine or other antipsychotic therapy
Treatment recommended for ALL patients in selected patient group
There are no clear studies demonstrating superiority of specific antipsychotics as augmentation with electroconvulsive therapy (ECT).
In studies of patients with schizophrenia, symptoms and rates of remission improved with clozapine plus ECT treatment compared with clozapine alone.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021. https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841 [68]Petrides G, Malur C, Braga RJ, et al. Electroconvulsive therapy augmentation in clozapine-resistant schizophrenia: a prospective, randomized study. Am J Psychiatry. 2015 Jan;172(1):52-8. https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2014.13060787 http://www.ncbi.nlm.nih.gov/pubmed/25157964?tool=bestpractice.com Some evidence suggests antipsychotics other than clozapine may also be beneficial.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021. https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841
Consult a specialist for guidance on antipsychotic selection and dose.
psychosocial interventions
Treatment recommended for ALL patients in selected patient group
Psychosocial interventions are key components of long-term management. The Patient Outcomes Research Team (PORT) guidelines recommend the following psychosocial interventions: assertive community treatment, supported employment, skills training, cognitive behavioural therapy (CBT), token economy interventions, and family-based services.[47]Kreyenbuhl J, Buchanan RW, Dickerson FB, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr Bull. 2010 Jan;36(1):94-103.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800150
http://www.ncbi.nlm.nih.gov/pubmed/19955388?tool=bestpractice.com
[ ]
In people with chronic mental illnesses, how do life skills programs affect outcomes?/cca.html?targetUrl=https://cochranelibrary.com/cca/doi/10.1002/cca.564/fullShow me the answer CBT for psychosis (CBTp), cognitive remediation, psychoeducation, and supportive therapy have been shown to be effective and should be started early in treatment.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021.
https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841
[47]Kreyenbuhl J, Buchanan RW, Dickerson FB, et al. The Schizophrenia Patient Outcomes Research Team (PORT): updated treatment recommendations 2009. Schizophr Bull. 2010 Jan;36(1):94-103.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800150
http://www.ncbi.nlm.nih.gov/pubmed/19955388?tool=bestpractice.com
[56]Anaya C, Martinez Aran A, Ayuso-Mateos JL, et al. A systematic review of cognitive remediation for schizo-affective and affective disorders. J Affect Disord. 2012 Dec 15;142(1-3):13-21.
http://www.ncbi.nlm.nih.gov/pubmed/22840620?tool=bestpractice.com
Other interventions that may be beneficial include supportive psychotherapy, intensive case management, and cognitive enhancement treatment.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021.
https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841
CBTp is more efficacious in decreasing positive symptoms, and social skill training is efficacious in decreasing negative symptoms.[57]Turner DT, van der Gaag M, Karyotaki E, et al. Psychological interventions for psychosis: a meta-analysis of comparative outcome studies. Am J Psychiatry. 2014 May;171(5):523-38. http://www.ncbi.nlm.nih.gov/pubmed/24525715?tool=bestpractice.com [58]Jauhar S, McKenna PJ, Radua J, et al. Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. Br J Psychiatry. 2014 Jan;204(1):20-9. http://www.ncbi.nlm.nih.gov/pubmed/24385461?tool=bestpractice.com
A minimum duration of 16 CBTp sessions is recommended.[32]American Psychiatric Association. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia, third edition. Washington, DC: American Psychiatric Association; 2021. https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841 [59]National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. March 2014 [internet publication]. https://www.nice.org.uk/guidance/cg178 However, studies suggest that treatment benefits may no longer be significant after 6 months.
Monitor for depressive symptoms and risk factors for suicide. Case management should be implemented early in the illness process.
Family issues need to be addressed early because interventions are useful in relapse prevention.
general health maintenance
Treatment recommended for ALL patients in selected patient group
Schizoaffective disorder is associated with increased frequency of medical illnesses and with a 15- to 20-year reduction in life expectancy. Managing the adverse effects of medications is crucial because many of these agents further increase the risk of medical illness. Health maintenance is, therefore, targeted to these adverse effects.
Possible adverse effects include neurological adverse effects, metabolic abnormalities (weight gain, blood glucose levels), hyperprolactinaemia, cardiac abnormalities, agranulocytosis, postural hypotension, and anticholinergic adverse effects.
antidepressant
Treatment recommended for ALL patients in selected patient group
An antidepressant can be added to antipsychotic medication for patients who have symptoms of depression associated with the illness. Antidepressants should be prescribed conservatively, mostly during the course of a depressive episode, in order to avoid a precipitation of a manic or mixed episode.
Primary options
fluoxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 80 mg/day
OR
paroxetine: 20 mg orally once daily initially, increase gradually according to response, maximum 50 mg/day
OR
citalopram: 20 mg orally once daily initially, increase gradually according to response, maximum 40 mg/day
OR
sertraline: 50 mg orally once daily initially, increase gradually according to response, maximum 200 mg/day
OR
mirtazapine: 15 mg orally once daily initially, increase gradually according to response, maximum 45 mg/day
mood stabiliser
Treatment recommended for ALL patients in selected patient group
A mood stabiliser can be added to antipsychotic medication for manic or mixed symptoms associated with the illness.
Serum drug levels should be monitored - therapeutic levels can vary between laboratories.
In 2018, the European Medicines Agency (EMA) recommended that valproate and its analogues are contraindicated in bipolar disorder during pregnancy due to the risk of congenital malformations and developmental problems in the infant/child.[52]European Medicines Agency. New measures to avoid valproate exposure in pregnancy endorsed. 23 March 2018 [internet publication]. https://www.ema.europa.eu/en/documents/referral/valproate-article-31-referral-new-measures-avoid-valproate-exposure-pregnancy-endorsed_en.pdf The EMA did not comment specifically on use of valproate during pregnancy in schizoaffective disorder, but it is reasonable to extrapolate that this is also contraindicated. In the US, standard practice is that valproate and its analogues are only prescribed for the treatment of manic episodes associated with bipolar disorder or schizoaffective disorder during pregnancy if other alternative medications are not acceptable or not effective. In both Europe and the US, valproate and its analogues must not be used in female patients of childbearing potential unless there is a pregnancy prevention programme in place and certain conditions are met.[52]European Medicines Agency. New measures to avoid valproate exposure in pregnancy endorsed. 23 March 2018 [internet publication]. https://www.ema.europa.eu/en/documents/referral/valproate-article-31-referral-new-measures-avoid-valproate-exposure-pregnancy-endorsed_en.pdf
Primary options
lithium: 300 mg orally (regular-release) two to three times daily initially, increase gradually according to response and serum drug level, maximum 2400 mg/day
OR
carbamazepine: 200 mg orally (extended-release) twice daily initially, increase gradually according to response and serum drug level, maximum 1600 mg/day
OR
valproate semisodium: 250 mg orally three times daily initially, increase gradually according to response and serum drug level, maximum 60 mg/kg/day (monitor carefully if dose >45 mg/kg/day)
OR
lamotrigine: dose may depend on what drugs a patient is currently on; consult specialist for guidance on dose
Choose a patient group to see our recommendations
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
Use of this content is subject to our disclaimer