GuidelinesOther guideline
Summary points
These are the approved guidelines published by the South African Society of Psychiatrists to provide an overview on treatment and management of commonly diagnosed psychiatric illnesses. The guidelines include consensus recommendations, based on peer contribution and using the international evidence based guidelines that are suitable for the local South African health service.
Please note that parts of this guideline may be out of date, an update will be published as soon as it is available.
- Both typical FGA agents and atypical SGA agents are effective in schizophrenia. Any differences in efficacy between these agents are small to modest. There are, however, clear differences in side-effect profiles.
- Monotherapy is recommended as there is no advantage to combining antipsychotics.
- A loading dose (‘rapid neuroleptisation’) is ill-advised, as it confers no therapeutic benefit with added risks.
- Risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone and amisulpride are effective in first-episode psychosis patients.
- For multi-episode patients, consider risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone and amisulpride. Haloperidol and chlorpromazine may be considered as alternatives to FGAs.
- A trial of 4 - 6 weeks is required before considering an alternative agent.
- A second trial agent may be another SGA or an FGA, but should be an SGA if there was a failed response to an FGA in the first trial. Third-line treatment is clozapine.
- Clozapine is more effective than other FGA and SGA agents in treatment resistance and reduction of suicide risk.
- If there is an insufficient response to a maximum dose clozapine, consider combining clozapine with another SGA, or augmenting with a mood stabiliser, ECT, or adding a benzodiazepine in the short-term to control agitation or disruptive behaviour.
- Half of all patients stopping medication will relapse within 6 - 10months, compared to one-fifth on treatment.
- Minimum treatment duration for first episode patients is 1 year symptom-free if the episode is of mild severity and responds well to treatment, and 2 years symptom-free in severe cases or those slow to respond initially.
- Second-episode patients require at least 2 - 5 years of medication while symptom-free before discontinuation is considered, while patients who have had 3 or more episodes should be treated indefinitely.