Schizophrenia Spectrum Disorders (Schizophrenia)

Description

General Measures 

Medicine Treatment 

Referral

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ICD-10 code: F20-F20.9/F21/F22.0-22.9; F25.0-25.9 + (F10.0-F19.9/R45.0-8/Z65.0-5/Z65.8-9/Z81.0-4/ Z81.8)

Description

Schizophrenia is the most common, chronic psychotic disorder and is characterised by recurrent, severe, psychotic episodes which are accompanied by a marked deterioration in personal, social, and occupational functioning.

Onset is usually in adolescence or young adulthood. Prognosis is worsened with delay in initial treatment, repeated episodes, and comorbid substance use. Comorbid substance use and medical conditions (e.g., metabolic syndrome) are common.

The diagnosis of schizophrenia should be confirmed by a specialist. In stable patients with good insight and support, primary care facilities may continue treatment and social support.

General Measures

• See: Psychiatric patients - general monitoring and care.
• Supportive intervention includes:
  • Psychoeducation of the patient and their family regarding the nature of schizophrenia, the importance of treatment adherence, and early signs of recurrent episodes.
  • Supportive group therapy for patients with schizophrenia.
• Rehabilitation may be enhanced by:
  • Assertive community programs.
  • Occupational therapy.
  • Work assessment, and bridging programmes.
  • Appropriate placement and supported employment.
• Assessment of risk to self and others, and early signs of relapse should be performed at every review.

Medicine Treatment

Adults

• Haloperidol, oral. (Doctor prescribed).
  • Initial dose: 1.5 mg daily, increasing to 5 mg daily, if initial treatment tolerated and according to clinical response.
  • Once stabilised, administer as a single dose at bedtime.

Elderly

• Haloperidol, oral. (Doctor prescribed)
  • Initial dose: 0.75 mg twice daily.
  • Increase dose more gradually until symptoms are controlled or until a maximum of 5 mg daily, if tolerated, is reached.
  • Once stabilised, administer as a single dose at bedtime.

See: Special considerations: Older patients (≥ 45 years).

LoE:IVb

If there is a good response / tolerability to haloperidol, or patient’s preference:

• Flupenthixol decanoate, IM, 10–40 mg every 4 weeks. (Doctor prescribed).
  • Initial dose: 10 mg.

OR

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

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Note:
- Patients should initially be stabilised on an oral antipsychotic agent before changing to a depot preparation.
- Administer an initial test dose of the depot antipsychotic and observe the patient for 1 week before administering higher doses.
- Reduce the oral antipsychotic formulation, stopping once patient is stabilised on the long-term depot therapy.
- Long-acting injectable antipsychotics are particularly useful in patients unable to adhere to their oral medication regimens, but need to be accompanied by a track and trace programme to be effective for adherence.
- Long-term therapy should always be in consultation with a doctor or, if available, with a psychiatrist. Patients should be re-assessed every 6 months.

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For breakthrough episodes on an injectable antipsychotic, consider additional short-term therapy of:

• Risperidone, oral 2 mg daily (Doctor prescribed).

If good response to IM antipsychotic but patient has extrapyramidal side effects (EPSEs), add:

• Anticholinergic, e.g.:
• Orphenadrine, oral, 50 mg 8 hourly, and refer for review of medication.

LoE:IVb²³

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Note:
- Anticholinergic medicines (e.g. orphenadrine) should not be used routinely as prophylaxis to prevent EPSEs to antipsychotic medication.
- For management of extra-pyramidal adverse drug reactions and acute dystonic reactions: See: Extra-pyramidal side effects.

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If poor response, to IM antipsychotic or poor EPSE response to anticholinergic switch to risperidone:

• Risperidone, oral, 2 mg daily (Doctor prescribed).
  • Increase to 4 mg daily if there is a poor response after 4 weeks.

If patient is already stabilised on chlorpromazine:

• Chlorpromazine, oral (Doctor prescribed).
  • Maintenance dose: 75–300 mg at night, but may be as high as 800 mg.

Referral

• Poor social support.
• High suicidal risk or risk of harm to others.
• Children and adolescents.
• The elderly.
• Pregnant and lactating women.
• No response or intolerance to medicine treatment.
• Concurrent medical or other psychiatric illness.
• Epilepsy with psychosis.
• Early sign of relapse.

Click here for the pdf

Click here for the circular 

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Standard Treatment Guidelines and Essential Medicines List for South Africa Primary Healthcare Level_Chapter 16: Mental Health Conditions_NEMLC Recommendations for Medicine Amendments 2020_2023