Schizophrenia Spectrum Disorders

Description

General Measures

Medicine Treatment

Adverse Effects

Referral

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ICD - 10 code: F20.0-6/F20.8-9/F22.0-9/F25.0-2/F25.8-9 + (F10.0-F19.9/R45.0-8/Z65.0-5/Z65.8-9/Z81.0- 4/Z81.8)

Description

Schizophrenia is characterised by psychotic episodes which are severe, persistent, and accompanied by a marked deterioration in personal, social, and occupational functioning.

Whilst the presentation may be acute, typically the illness has a chronic, relapsing course with progressive cognitive and functional decline. Onset is usually in youth. Prognosis is worsened with delay in initial treatment, repeated episodes, and comorbid substance use. Comorbid metabolic syndrome and cardiovascular disease are common.

General Measures

Manage all patients in consultation with a psychiatrist.
Diagnostic certainty requires careful observation and re-evaluation over time.

Acute psychosis

• Assess risk to self and others.
• Clarify diagnosis.
• Manage within a multi-disciplinary team.
• Use shared decision-making in treatment process.
• Involve family and carers with patient’s permission unless risk to self/others necessitates a breach of confidentiality.
• Provide psychoeducation to patient, family, and carers on the nature of the illness, need for continued treatment, how to self-monitor, early signs of relapse, and need for structure and routine.

Maintenance treatment

• Provide antipsychotic maintenance treatment to prevent relapse.
• Community-based nursing with adherence support, repeated risk assessment, and shared decision-making is required.
• Refer to occupational therapy for functional rehabilitation.
• Monitor psychiatric symptoms (use rating scales, e.g. BPRS or PANSS).
• Monitor extra-pyramidal side effects, weight, blood pressure, and glucose every 6 months.
• Adjust treatment according to response, adverse effects, and comorbidity.
• Provide lifestyle and dietary education; encourage exercise.
• Treat comorbid mood disorders (see Mood disorders: Bipolar and Related Disorders and Depressive Disorders).
• Treat comorbid hypertension (see: Hypertension), diabetes mellitus (see: Diabetes mellitus), and other medical conditions as needed.
• Manage substance use – refer for rehab (South African National Council on Alcoholism and Drug Dependence [SANCA], Social Development).
• Poor adherence with recurrent episodes:
  • Check reasons – illness, medication, patient factors.
  • Poor response/ tolerability to medication – change to alternative antipsychotic.
  • Poor insight - try depot antipsychotic – start with test dose (half initial dose in algorithm below).
  • Address psychosocial factors, substance use.
• Refer to social worker for placement in a residential home, day care or sheltered employment/workshop as needed.

Women in reproductive age-group (See Primary Health Care STGs and EML, Maternal mental health).

• Advise family planning – psycho-educate regarding need to plan pregnancy and comply with antenatal care.
• If patient is a parent/guardian – support childcare; refer to social worker if impaired.
• Risk of psychotic relapse is high in pregnancy and postpartum including the first year post-delivery.
• In pregnancy: continue antipsychotic treatment; Monitor closely for weight gain, gestational diabetes, psychotic relapse, and/or substance use.

Medicine Treatment

Acute psychotic episode

• Treat severe aggression and disturbed behaviour as in Aggressive Disruptive Behaviour in Adults.
• Initiate treatment with a view to long-term management.
• Assess risk factors for the development of tardive dyskinesia: age >50 years, female sex, prominent mood symptoms, cognitive or neurological disturbance e.g. intellectual disability, autistic spectrum, People living with HIV (PLHIV).
• In patients with high risk of tardive dyskinesia: Avoid haloperidol and antiparkinsonian medicines. Use chlorpromazine, risperidone or olanzapine at lowest doses needed to achieve desired effect.

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Initiate treatment:

• Haloperidol, oral, 0.75–1.5 mg daily.
  • Increase to 5 mg daily if initial treatment tolerated and according to clinical response.

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If good response/tolerability to haloperidol, or patient preference:

• Depot antipsychotic, e.g:
• Flupenthixol decanoate, IM, 10–40 mg every 4 weeks.
  • Initial dose: 10mg

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OR

• Zuclopenthixol decanoate, IM, 100–400 mg every 4 weeks.
  • Initial dose: 100mg

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If poor response/ poorly tolerated/ high risk of tardive dyskinesia/ extra-pyramidal side effects:

• Risperidone, oral
  • Initial dose: 2–4 mg at night.
  • Assess efficacy after 4–6 weeks:
    • If a partial response is noted, increase the dosage.
    • If no response is noted, switch treatment.
  • Maximum dose: 6 mg daily

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OR

• Chlorpromazine, oral, 75–300 mg at night, but may be increased to 800mg a day in 2–3 divided doses according to clinical response.

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If poor response/tolerability to haloperidol, risperidone, and chlorpromazine:

• Olanzapine, oral (specialist initiated).
  • Initial dose: 5 mg at night, increase to 10 mg at night.
  • Maximum dose: 20 mg at night.

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If poor response/tolerability to olanzapine:

• Clozapine, oral (specialist initiated, preferably as inpatient):
  • Initial dose: 12.5–25 mg at night.
  • Usual dose: 200–450 mg per day in 2 divided doses.
  • Maximum dose: 900mg/day in 2 divided doses. 

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CAUTION - CLOZAPINE
May cause neutropenia (3% of cases) and agranulocytosis (0.8% of cases):
- Pre-treatment: Check that white cell count and absolute neutrophil count are normal.
- Monitor absolute neutrophil count regularly.
- Withdraw clozapine and review medication if neutrophils <1.0 x109/L (general population).

Myocarditis: highest risk in first two months of treatment. Monitor pulse, blood pressure, temperature; advise patient to report any palpitations, shortness of breath, chest pain, fever immediately.

Seizures: risk increased at doses >450 mg/day.
- Manage as for epilepsy (see: Epilepsy).
- Lamotrigine is preferred as it is weight neutral and does not interfere with clozapine metabolism.
- Avoid carbamazepine because of possible myelosuppression and enzyme induction.

Constipation: avoid anticholinergics; may require laxatives; prolonged discomfort may indicate intestinal obstruction.

Weight gain, diabetes, dyslipidaemia: Manage as per PHC STGs and EML, see: Psychiatric patients general monitoring and care; see: Ischaemic heart disease and atherosclerosis, prevention, and see: Type 2 diabetes mellitus.

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OR

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If poor response to olanzapine and clozapine is not an option due to metabolic effects (weight gain, type 2 diabetes) or persistent negative symptoms are present:

• Refer to tertiary and quaternary level care for amisulpiride if excessive weight gain and/or type 2 diabetes, or persistent negative symptoms.

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Adverse Effects

Extrapyramidal adverse effects

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Note:
Anticholinergic medicines (e.g. orphenadrine) should not be added prophylactically to antipsychotics to prevent extrapyramidal side effects.

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Acute dystonia: See the PHC STGs and EML, Extra-pyramidal side effects.

Parkinsonism:

ICD-10 code: G21.0-1

• Anticholinergic agent, e.g.:
• Orphenadrine, oral, 50–150 mg daily according to individual response.
  • Usual dose: 50 mg 8 hourly.
  • Maximum dose: 150 mg daily.
  • Use with caution in the elderly as it may cause confusion and urinary retention.
  • Review antipsychotic treatment, and stop orphenadrine if medicine changed.

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Akathisia:

ICD-10 code: G25.8

A subjective unpleasant state of inner restlessness where there is a strong desire or compulsion to move:

• Propranolol, oral,
  • Start at 20 mg daily and titrate as needed up to 80 mg 8 hourly.
  • Monitor pulse and blood pressure.

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Neuroleptic Malignant Syndrome:
See the PHC STGs and EML, Neuroleptic malignant syndrome.

Referral

All patients to be managed in consultation with a psychiatrist, refer as advised, particularly if:

• High risk to self or others at any time.
• If diagnosis is uncertain.
• Poor response to treatment.

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Standard Treatment Guidelines and Essential Medicines List for South Africa Adult Hospital Level_Chapter 15: Mental Health Conditions and Substance Misuse_NEMLC Recommendations for Medicine Amendments 2020_2023