F20.0-6/F20.8-9 + (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 a loss of contact with reality. It is further characterised by:
- positive symptoms, delusions, hallucinations and thought process disorder
- negative symptoms, blunting of affect, social withdrawal
- mood symptoms such as depression may be present
Clinical features include:
- delusions: fixed, unshakeable false beliefs (not shared by society)
- hallucinations: perceptions without adequate corresponding external stimuli, e.g. hearing voices
- disorganised thoughts and speech: e.g. derailment or incoherence
- grossly disorganised or catatonic behaviour
- negative symptoms: affective flattening, social withdrawal
- social and/or occupational dysfunction
The diagnosis of schizophrenia should be confirmed by a specialist. In stable patients with good insight and support, primary care facilities may continue treatment.
GENERAL MEASURES
- Supportive intervention includes:
- Family counselling and psycho-education for patient and family.
- 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
Schizophrenia where a less sedating agent is required:
Adults
- Haloperidol, oral. (Doctor prescribed)
- Initial dose: 1 mg daily, increasing to 5 mg daily.
- 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).
If extrapyramidal side effects: switch to risperidone rather than adding an anticholinergic medicine:
- Risperidone, oral (Doctor prescribed).
- Initial dose: 2 mg daily.
- Increase to 4 mg daily, if poor response after 4weeks.
Note: Anticholinergic medicines (e.g. orphenadrine) should not routinely be added prophylactically to antipsychotics to prevent extrapyramidal side effects.
Patients already stabilised on chlorpromazine:
- Chlorpromazine, oral (Doctor initiated).
- Maintenance dose: 75–300 mg at night, but may be as high as 800 mg.
Only for health care workers with advanced psychiatric training:
Long-term depot therapy where adherence problem, or patient preference:
- Flupenthixol decanoate, IM, 20–80 mg every 4 weeks.
- Initial dose: 20 mg.
OR
- Zuclopenthixol decanoate, IM, 200–600 mg every 4 weeks.
- Initial dose: 100 mg.
Note: Initially, patients should be stabilised on an oral antipsychotic agent before changing to a depot preparation. Administer an initial test dose 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.
For breakthrough episodes, consider short-term therapy of:
- Risperidone, oral 2 mg daily (Doctor prescribed).
- Long-acting 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.
For management of extra-pyramidal adverse drug reactions and acute dystonic reactions: See: Extra-pyramidal side effects .
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.