Schizoaffective Disorder

Background

• Schizoaffective disorder is a chronic psychotic disorder in which classic schizophrenia symptoms (such as delusions, hallucinations, and disorganized speech) occur in conjunction with major mood symptoms (either depressive or manic episodes) for the majority of the illness duration.
• Disease classification of schizoaffective disorder is controversial, and there is ongoing debate over whether schizoaffective disorder represents a form of schizophrenia, a form of a mood disorder with psychotic features, or a distinct, heterogeneous disorder.
• Risk factors for schizoaffective disorder include family history of psychotic disorder and childhood abuse or neglect.

Evaluation

• Suspect schizoaffective disorder in patients with psychotic symptoms and major mood symptoms such as depression or mania.
  • Psychotic features may include paranoid delusions, hallucinations, and disorganized speech.
  • Depressive symptoms may include anhedonia, low energy, poor sleep, poor concentration, poor appetite, and reduced drive or volition.
  • Manic symptoms may include elevated mood, grandiosity, rapid speech, distractibility, intrusiveness, increased goal-directed behavior and energy, disorganization, hypersexuality, and racing thoughts.
• Diagnosis of schizoaffective disorder is challenging due to the lack of clear distinction between schizoaffective disorder and other mood and psychotic disorders seen in clinical practice, particularly schizophrenia and bipolar disorder.
  • Psychotic and mood symptoms may present concurrently or in an alternating manner, but mood symptoms must be present for ≥ 50% of the duration of the illness for diagnosis according to Diagnostic and Statistical Manual of Mental Disorders, 5th ed. criteria.
  • Establishing the proportion of mood vs. psychotic symptoms can be difficult and requires careful history taking.
• Perform a detailed psychiatric history.
  • Determine the temporal relationship between psychotic and mood symptoms.
  • Ask about the patient's family history of psychotic and mood disorders.
  • Assess the patient's response to any prior psychiatric treatment.
  • Perform a careful and ongoing evaluation of suicide risk.
  • Evaluate for psychosocial stressors, substance use, and other co-occurring psychiatric conditions.
• Perform a targeted physical exam if a medical condition is suspected to be causing psychotic symptoms.
• Important differential diagnoses to consider include schizophrenia, bipolar disorder, major depressive disorder, and other conditions that may cause psychotic symptoms.

Management

• Evidence for the management of schizoaffective disorder is limited and is often extrapolated from trials that include a large proportion of patients with schizophrenia or other psychotic disorders.
• Offer a multidisciplinary approach that includes pharmacologic management and comprehensive psychosocial support.
• Antipsychotic monotherapy is first-line treatment for schizoaffective disorder.
  • Offer oral second-generation antipsychotics as first- and second-line therapy. Start antipsychotic therapy at a low dose and gradually increase at intervals if the response is inadequate, unless acute illness requires urgent treatment with a higher starting dose.
  • Individualize the selection of antipsychotic medication based on its anticipated efficacy, its adverse-effect profile, and patient preferences.
    • Paliperidone, a second-generation antipsychotic, is FDA approved for schizoaffective disorder.
    • Other second-generation antipsychotics with direct evidence for efficacy in schizoaffective disorder include aripiprazole, risperidone, and ziprasidone.
    • Based on indirect evidence, most antipsychotics appear to be associated with a similar risk of relapse in adults with schizophrenia or schizoaffective disorder.
  • If treatment response during the acute phase was adequate, it is generally advisable to continue maintenance therapy with the same antipsychotic medication, unless intolerable adverse effects develop.
  • Routinely monitor for effectiveness, tolerability, and adherence in all patients taking antipsychotics.
    • Nonadherence to medication therapy is common in patients with schizoaffective disorder and is associated with increased risk for relapse.
      • Frequently discuss the risks of nonadherence, and explore the patient's reasons for nonadherence, particularly the adverse effects of medications.
      • Long-acting injectable formulations, such as once-monthly paliperidone palmitate, may improve medication adherence and reduce relapse.
    • Consider switching antipsychotic medications if there is an inadequate response to treatment or if intolerable adverse effects develop.
      • Medications may be changed by immediate switching or by gradually overlapping medications as the first medication is tapered off and the second medication is added.
      • Closely monitor for discontinuation withdrawal symptoms during switching, and offer short-term adjuvant medications to address rebound symptoms.
    • If there is treatment resistance, consider a trial of clozapine for 12 months, but offer frequent monitoring due to the high burden of adverse effects. If clozapine is insufficient, consider adding another medication, adding electroconvulsive therapy, or switching to another antipsychotic.
• The addition of mood stabilizers or antidepressants to antipsychotic medications may be considered to address mood symptoms, but evidence is limited.
  • Mood stabilizers such as lithium and sodium valproate may be added to antipsychotic therapy to address affective symptoms.
  • The addition of antidepressant medication to antipsychotic therapy may be used, but with careful consideration of potential drug-drug interactions and additional side effects.
  • Antidepressant monotherapy might improve depression without addressing psychotic symptoms or cognitive decline.
• Offer psychosocial interventions in addition to antipsychotic therapy. Psychosocial interventions that have been studied in persons with schizoaffective disorder include the following:
  • Cognitive behavioral therapy for psychosis, if available, is applicable to any treatment setting.
  • Psychoeducation therapy is typically used in outpatient settings but may be incorporated into inpatient care.
  • Family-based interventions often incorporate psychoeducational approaches and use a consultative framework that may involve the patient, family and/or other support persons, and professional therapists to provide structured therapy.
  • Cognitive remediation therapy is a form of cognitive rehabilitation that may be used as a sole intervention or in conjunction with other psychiatric interventions.