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These guidelines cover the management of schizophrenia. However, a diagnosis of schizophrenia is often made over a period of time so the 'Initial psychotic episode' guidance applies to pharmacologically treating brief psychotic episodes including drug-induced psychosis.
Psychological and psychosocial interventions should be offered to all people with schizophrenia, starting either during the acute phase (including in-patient settings) or later, but are beyond the scope of this guideline.
Guidance from an appropriate specialist mental health clinician should be sought in all instances of psychotic illness unless the practitioner is experienced at managing these conditions.
Offer oral antipsychotic medication. The choice of drug should be made jointly by the individual and healthcare professional, considering:
There is no evidence of improved efficacy between first generation antipsychotic drugs and second-generation antipsychotics, with the exception of clozapine.
Use the most appropriate antipsychotic based on its side effect profile and licensed indications. Do not exceed BNF maximum doses. At the start of treatment give a dose at the lower end of the licensed range and slowly titrate upwards within the dose range given in the BNF or SPC. Do not use loading doses of antipsychotic drugs. Carry out a trial of the medication at the optimum dosage for 4–6 weeks.
Risperidone is considered the treatment of choice if there is no preference between available antipsychotic treatments, based on clinical presentation and/ or individual preference.
Acute psychosis is often accompanied by anxiety, and less often by behavioural disturbance. These symptoms are best dealt with by the concurrent prescription of a benzodiazepine e.g. diazepam 2-5mg up to three times daily. As the anxiety/behavioural disturbance settles the benzodiazepine should be reduced and discontinued.
Schizophrenia is associated with an increased incidence of diabetes and some second generation antipsychotics have been associated with increased rates of glucose intolerance and diabetes. It is advised that a specialist psychiatrist is consulted when treating people prescribed antipsychotics with newly emergent diabetes and commencing people on antipsychotics with existing diabetes.
See guidance below for alternative antipsychotics appropriate to be prescribed in certain circumstances or conditions. It is not a substitute for the BNF or SPC but can help guide the individual in their choice. (Adapted from Bazire; Psychotropic Drug Directory 2009)
Refer to the individual's history looking for previous evidence of successful pharmacological treatment. The same principles of individual-led choice apply in order to promote improved concordance with the prescribed regime. Take into account the clinical benefit and side effects experienced by the individual with any previous medication.
Prescribing antipsychotics for patients presenting with psychosis should be commenced after seeking specialist advice. However, you may wish to prescribe without seeking specialist advice if you feel confident in prescribing such medications in such circumstances, e.g. an existing patient suffering a recurrent acute episode previously managed on antipsychotic treatment.
When initiating depot/long-acting injectable antipsychotic medication:
Consider offering depot antipsychotic medication to people with schizophrenia:
Initially use a small test dose as set out in the BNF or SPC.
Pipotiazine depot injection will be discontinued from the end of March 2015. No new patients will receive pipotiazine. Patients currently receiving pipotiazine will be switched to an alternative treatment.
Long-acting aripiprazole, olanzapine and paliperidone injections are currently approved as hospital only drugs until other service arrangements are in place.
Specific indications for these medications in people with schizophrenia are:
Do not use combinations of two or more antipsychotics except where:
For people with schizophrenia whose illness has not responded adequately to pharmacological or psychological treatment:
Clozapine (See section 4.2 Drugs used in psychoses and related disorders) may be offered to people with schizophrenia whose illness has not responded adequately to treatment despite the sequential use of adequate doses of at least two different antipsychotic drugs. At least one of the drugs should be a non-clozapine atypical antipsychotic.
For people with schizophrenia whose illness has not responded adequately to clozapine at an optimised dose, healthcare professionals should consider the points above (including measuring therapeutic drug levels) before adding a second antipsychotic to augment treatment with clozapine. An adequate trial of such an augmentation may need to be up to 8–10 weeks.
Patients with schizophrenia should have physical health monitoring at least once a year.
Focus on cardiovascular disease risk assessment but bear in mind that people with schizophrenia are at a higher risk of CVD than the general population.
Inform the individual that there is a high risk of relapse if they stop medication in the next 1–2 years. If antipsychotic medication has to be withdrawn, reduce the dose gradually and monitor regularly for signs and symptoms of relapse. After withdrawal from antipsychotic medication, continue monitoring for signs and symptoms of relapse for at least 2 years.
In cases of acute and severe adverse effects (i.e. blood dyscrasia with clozapine) where abrupt discontinuation of medication is required, specialist advice should be sought to ensure adequate support is available and to ensure an urgent review of treatment is completed.
Prescribing for elderly patients – start low and go slow. The lowest effective dosage of medications should be used, monitor frequently
Patients aged over 65 years of age have an increased sensitivity to medications as a result of age–related alterations in pharmacodynamics (changes in neuronal cell numbers, receptors and receptor binding) and pharmacokinetics (changes in absorption, distribution, metabolism, excretion and protein binding). Especially significant is the reduced liver metabolism and declining renal clearance, associated with increasing age.
Avoid polypharmacy; the elderly are at increased risk of adverse neuropsychiatric complications from drug interactions. Consider the possibility of concomitant use of over the counter (OTC) medications. Always consider drug toxicity when the patient exhibits alterations in attention or cognitive or any behavioural change.
Avoid the use of drugs which put the elderly at risk of falls, especially sedative hypnotics, benzodiazepines, phenobarbital, phenytoin.
The elderly are much more sensitive to orthostatic hypotension and anticholinergic effects. Drugs with a high degree of anticholinergic activity should be avoided. Tricyclics should be used with caution, especially those with a higher degree of anticholinergic activity, for example, amitriptyline. Selective serotonin re-uptake inhibitors are better tolerated.
Electroconvulsive therapy (ECT) is a safe and effective treatment option in this population for severe depression and mania.
Lithium clearance is reduced in the elderly and lithium toxicity may occur at levels that would be considered “therapeutic" in younger patients. Required doses may be up to 50% lower compared with younger patients.
The elderly are more susceptible to the extrapyramidal symptoms of antipsychotics as well as to the orthostatic hypotension and cholinergic effects of these agents. When indicated, they should be used in much lower doses (generally one half to one third of doses in younger adults) and titrated more slowly with frequent monitoring. Overall atypical antipsychotics have a more favourable side effect profile compared to traditional antipsychotics.
There is a 3-fold increased risk of cerebrovascular adverse events in people with dementia treated with the atypical antipsychotics, risperidone and olanzapine. The CSM advises 'potentially similar risk' of increase in cerebrovascular adverse events with quetiapine but there are no studies confirming this.
Seek expert advice, the National Teratology Information Service offers up-to-date information on all medicines in pregnancy. Tel: 0844 892 0909 (8.30 – 17.00 Monday to Friday)