Schizophrenia

Background

• Schizophrenia is a chronic psychiatric disorder with variable outcome characterized by persistent psychotic symptoms of delusions, hallucinations, and disorganized speech, and negative symptoms, such as apathy and flattened affect.
• Onset of schizophrenia is typically in young adulthood, and the lifetime prevalence of schizophrenia is 0.3%-0.7%.
• The cause of schizophrenia is unknown, but likely results from complex interactions between multiple genetic and environmental factors.

Evaluation

• Patients with psychotic symptoms should be carefully evaluated for alternative causes, including medications or illicit drugs, medical conditions associated with delirium or dementia, other psychiatric conditions including mood disorders with psychosis, affective disorders and mania, and autism spectrum disorders.
• The diagnosis of schizophrenia is made clinically based on persistent (> 6 months) symptoms of delusional or hallucinatory behavior and negative symptoms, after alternative diagnoses are ruled out.
• Consider the use of formal criteria such as the ICD-10 criteria or Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for the diagnosis.

Management

• Antipsychotic medications are the initial treatment choice for schizophrenia. When selecting an antipsychotic, review its effectiveness and adverse effect profile, particularly motor side effects, metabolic side effects, and cardiovascular side effects, and how these may affect individual patients.
  
• For first-episode schizophrenia:
  • Consider starting with an atypical antipsychotic over a typical antipsychotic.
  • Consider clozapine and olanzapine as second-line options due to their adverse effect profile.
• For patients with relapse or multiple-episode schizophrenia:
  • Assess any potential contributing factors, such as nonadherence, substance use, and stress.
  • Adjust antipsychotic dose if there is suboptimal dosing or a premature dose reduction.
  • If the patient is nonadherent due to adverse effects, consider switching to another antipsychotic medication.
  • Consider use of a long-acting injectable (LAI) antipsychotic (also known as a depot) medication as an alternative to oral antipsychotic treatment.
  • The routine use of 2 or more antipsychotic medications at the same time is not recommended; consider combining antipsychotics only for patients refractory to 3 adequate trials of antipsychotic monotherapy, including a failed trial of clozapine.
• For comorbid symptoms, consider other classes of medication. For anxiety, consider benzodiazepines; for depression, consider antidepressants, or lithium if needed for suicidality.
• For patients on any antipsychotic medication, monitor for adverse effects, including acute neurologic effects, such as akathisia and dystonia after starting the medication, and cardiovascular or metabolic effects, such as weight gain with long-term treatment.
• For children and adolescents with schizophrenia, use antipsychotic medication as the first-line medication treatment.
• Consider the addition of psychosocial interventions in conjunction with antipsychotic medications in management of schizophrenia.
  • Primary aims are to strengthen and sustain recovery, improve quality of life and adaptive functioning, and reduce or eradicate symptoms.
  • Options may include:
    • Multicomponent interventions such as structured psychotherapies, psychoeducation, skills training, family-based interventions, community care, and other therapeutic components;
    • Psychosocial therapies used alone or in combination include cognitive behavioral therapy, psychoeducation, supported employment services, assertive community treatment, family-based interventions, self-management interventions, cognitive remediation therapy, supportive psychotherapy, social skills training, and other counseling therapies.
• Consider other nonpharmacological interventions for patients with severe mental illness, such as crisis management, intensive case management, day hospital care, and supported employment.