Schizoaffective disorder Treatment Options - Epocrates Online https://online.epocrates.com/dx/indexprint?entire=false&iid=...

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Schizoaffective disorder
Treatment Options
Acute
Patient Group Tx Line Treatment

acute psychotic episode 1st start or review oral antipsychotic treatment

An acute psychotic episode may be the first psychotic episode or it may occur in the
setting of psychotic decompensation or resistance to antipsychotic medication.
The patient needs to be in a safe and predictable environment, and hospitalization
is often needed,
If the acute episode is the first presentation, the patient needs to be established on
antipsychotic medication. Such patients are usually naïve to antipsychotic agents
and should be started on low doses and the dose titrated according to response. [53]
Particular attention should be paid to adverse effects of the medication.
In a first acute psychotic episode, clozapine and olanzapine are not recommended.
Clozapine may be recommended for patients with multiple episode disorder who fail
at least 2 adequate trials of 2 different antipsychotic agents.
A trial of clozapine should last a minimum of 8 weeks. [53]

Routine checking of serum clozapine levels is not recommended; however, for

clozapine non-responders it is recommended that the dose be increased, adverse
effects permitting, for a target level >350 nanograms/mL.
Clozapine is available only under a restricted access scheme in the US and many
other countries. WBC count and absolute neutrophil count should be tested
periodically, owing to the risk of potentially life-threatening agranulocytosis.
If the acute episode is due to psychotic decompensation or to antipsychotic
resistance, the medication dose often needs to be increased or a new antipsychotic
medication started. If the patient has previously responded to a specific agent and
the acute episode is a result of noncompliance, treatment can be titrated to the
previously effective dose.

Primary Options

paliperidone : 6 mg orally once daily initially, increase gradually according to

response, maximum 12 mg/day

ziprasidone : 20 mg orally twice daily initially, increase gradually according to

response, maximum 160 mg/day

aripiprazole : 10-15 mg orally once daily initially, increase gradually according to

response, maximum 30 mg/day

risperidone : 1 mg orally twice daily initially, increase gradually according to

response, maximum 16 mg/day (usual range 4-8 mg/day), doses >6 mg/day
increase risk of extrapyramidal effects

quetiapine : 25 mg orally (immediate release) twice daily initially, increase gradually

according to response, maximum 800 mg/day; 300 mg orally (extended-release)
once daily initially, increase gradually according to response, maximum 800 mg/day

Secondary Options

olanzapine : 5-10 mg orally once daily initially, increase gradually according to

response, maximum 20 mg/day Olanzapine is not recommended in patients with a
first acute psychotic episode

clozapine : 12.5 mg orally once or twice daily initially, increase gradually according
to response, maximum 900 mg/day Clozapine is not recommended in patients with
a first acute psychotic episode

Tertiary Options

haloperidol : 0.5 to 5 mg orally two to three times daily initially, increase gradually
according to response, maximum 100 mg/day

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fluphenazine : 2.5 to 10 mg/day orally given in 3-4 divided doses initially, increase
gradually according to response, maximum 40 mg/day

trifluoperazine : 1-2 mg orally twice daily initially, increase gradually according to

response, maximum 40 mg/day

adjunct intramuscular antipsychotic

In cases of extreme agitation and violence, a short-acting intramuscular
antipsychotic medication can be given.

Primary Options

olanzapine : 5-10 mg intramuscularly as a single dose initially, a second dose may

be given 2-4 hours later if required, maximum 30 mg/day

aripiprazole : 5.25 to 9.75 mg intramuscularly as a single dose initially, a second

dose may be given at least 2 hours later if required, maximum 30 mg/day

ziprasidone : 10-20 mg intramuscularly as a single dose initially, may repeat 10 mg

every 2 hours or 20 mg every 4 hours if required, maximum 40 mg/day

adjunct anxiolytic
A short-acting intramuscular benzodiazepine such as lorazepam is often
administered in combination with the short-acting intramuscular antipsychotic.

Primary Options

lorazepam : 1-2 mg intramuscularly as a single dose, repeat every 8 hours if

required

Ongoing
Patient Group Tx Line Treatment

multiple-episode disorder 1st atypical antipsychotic

The first line of treatment should be an atypical antipsychotic agent other than
clozapine. [53] The benefits of these agents over older antipsychotics in terms of
decreased risk for extrapyramidal adverse effects and tardive dyskinesia need to be
balanced on an individual basis against the increased risk for weight gain and
metabolic syndrome, which is especially seen with olanzapine. [51]
For patients with established illness, information on previous treatments, dose,
duration of treatment, and response to each particular agent should be gathered.
Patients should be given the minimum dose that controls their symptoms, with
adequate follow-up for possible medication adjustments and monitoring of adverse
effects. Medication should be continued indefinitely but titrated or discontinued if
adverse effects are intolerable. There is no correlation between the drug dose and
therapeutic effect, but the risk of extrapyramidal signs (e.g., akathisia,
parkinsonism, and dystonia) increases with dose.
In people with treatment-responsive, multi-episode schizoaffective disorder who
are experiencing an acute exacerbation, the minimum recommended length of
treatment trial is 2 weeks, with an upper limit of 6 weeks to observe optimal
response.
For maintenance therapy, continuous treatment is recommended. Intermittent,
targeted treatment may increase the risk for symptom exacerbation and relapse,
and it is not recommended. [53]
If the first agent that is used fails, a trial with a different atypical antipsychotic agent
(other than clozapine) should be done.

Primary Options

paliperidone : 6 mg orally once daily initially, increase gradually according to

response, maximum 12 mg/day

olanzapine : 5-10 mg orally once daily initially, increase gradually according to

response, maximum 20 mg/day

ziprasidone : 20 mg orally twice daily initially, increase gradually according to

response, maximum 160 mg/day

aripiprazole : 10-15 mg orally once daily initially, increase gradually according to

response, maximum 30 mg/day

risperidone : 1 mg orally twice daily initially, increase gradually according to

response, maximum 16 mg/day (usual range 4-8 mg/day), doses >6 mg/day
increase risk of extrapyramidal effects

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quetiapine : 25 mg orally (immediate release) twice daily initially, increase gradually

according to response, maximum 800 mg/day; 300 mg orally (extended-release)
once daily initially, increase gradually according to response, maximum 800 mg/day

adjunct anxiolytic
Patients with symptoms of anxiety may benefit from the addition of an anxiolytic.
[56]

Studies have failed to demonstrate that buspirone is consistently effective against

panic attacks. [57] [58]

Primary Options

alprazolam : 0.25 mg orally (immediate-release) three times daily initially, increase

gradually according to response, maximum 4 mg/day

clonazepam : 0.25 mg orally twice daily initially, increase gradually according to

response, maximum 4 mg/day

diazepam : 2-10 mg orally two to four times daily

buspirone : 7.5 mg orally twice daily initially, increase gradually according to

response, maximum 60 mg/day

plus psychosocial interventions

Psychosocial interventions are key components of long-term management. In order
for patients to comply with treatment and for treatment to be successful, issues
such as tenuous housing, low income, inadequate work skills, poor social support,
and restricted access to health care need to be overcome.
Intensive case management reduces hospitalization, improves adherence to care,
and improves social functioning. [60] Assertive community treatment, supported
employment, skills training, cognitive behavioral therapy, cognitive remediation,
token economy interventions, and family-based services are recommended. [53] [59]
Patient education about illness and medication fosters insight and compliance. [61]

Monitor for depressive symptoms and risk factors for suicide. Case management
should be implemented early in the illness process.
Family issues need to be addressed early because interventions are useful in relapse
prevention.
CBT is more efficacious in decreasing positive symptoms, and social skill training is
efficacious in decreasing negative symptoms. [64] [65]

plus general health maintenance

Schizoaffective disorder is associated with increased frequency of medical illnesses
and with a 15- to 20-year reduction in life expectancy. Managing the adverse
effects of medications is crucial because many of these agents further increase the
risk of medical illness. Health maintenance is, therefore, targeted to these adverse
effects.
Possible adverse effects include neurological adverse effects, metabolic
abnormalities (weight gain, blood glucose levels), hyperprolactinemia, cardiac
abnormalities, agranulocytosis, postural hypotension, and anticholinergic adverse
effects.

2nd clozapine for treatment failure of 2 preferred atypical antipsychotic agents

Clozapine may be recommended for patients with multiple episode disorder who fail
at least 2 adequate trials of 2 different antipsychotic agents.
A trial of clozapine should last a minimum of 8 weeks. [53]

Routine checking of serum clozapine levels is not recommended; however, for

clozapine non-responders it is recommended that the dose be increased, adverse
effects permitting, for a target level >350 nanograms/mL.
Clozapine is available only under a restricted access scheme in the US and many
other countries. WBC count and absolute neutrophil count should be tested
periodically, owing to the risk of potentially life-threatening agranulocytosis.

Primary Options

clozapine : 12.5 mg orally once or twice daily initially, increase gradually according
to response, maximum 900 mg/day

plus psychosocial interventions

Psychosocial interventions are key components of long-term management. In order
for patients to comply with treatment and for treatment to be successful, issues
such as tenuous housing, low income, inadequate work skills, poor social support,
and restricted access to health care need to be overcome.

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Intensive case management reduces hospitalization, improves adherence to care,

and improves social functioning. [60] Assertive community treatment, supported
employment, skills training, cognitive behavioral therapy, cognitive remediation,
token economy interventions, and family-based services are recommended. [53] [59]
Patient education about illness and medication fosters insight and compliance. [61]

Monitor for depressive symptoms and risk factors for suicide. Case management
should be implemented early in the illness process.
Family issues need to be addressed early because interventions are useful in relapse
prevention.
CBT is more efficacious in decreasing positive symptoms, and social skill training is
efficacious in decreasing negative symptoms. [64] [65]

adjunct anxiolytic
Patients with symptoms of anxiety may benefit from the addition of an anxiolytic.
[56]

Studies have failed to demonstrate that buspirone is consistently effective against

panic attacks. [57] [58]

Primary Options

alprazolam : 0.25 mg orally (immediate-release) three times daily initially, increase

gradually according to response, maximum 4 mg/day

clonazepam : 0.25 mg orally twice daily initially, increase gradually according to

response, maximum 4 mg/day

diazepam : 2-10 mg orally two to four times daily

buspirone : 7.5 mg orally twice daily initially, increase gradually according to

response, maximum 60 mg/day

plus general health maintenance

Schizoaffective disorder is associated with increased frequency of medical illnesses
and with a 15- to 20-year reduction in life expectancy. Managing the adverse
effects of medications is crucial because many of these agents further increase the
risk of medical illness. Health maintenance is, therefore, targeted to these adverse
effects.
Possible adverse effects include neurological adverse effects, metabolic
abnormalities (weight gain, blood glucose levels), hyperprolactinemia, cardiac
abnormalities, agranulocytosis, postural hypotension, and anticholinergic adverse
effects.

3rd typical antipsychotic

The efficacy of these medications is well established, but they are not generally
recommended as initial treatment because they carry a higher likelihood of tardive
dyskinesia and worsening of negative symptoms.
Haloperidol use should be limited to situations when no other antipsychotic
medications with fewer extrapyramidal adverse effects can be used.
In pregnancy, typical antipsychotics appear less harmful than atypical antipsychotics
in terms of risk of gestational metabolic complications, increased weight for
gestational age, and birth weight.
Medication should be continued indefinitely, but should be titrated or discontinued
if adverse effects are intolerable.

Primary Options

haloperidol : 0.5 to 5 mg orally two to three times daily initially, increase gradually
according to response, maximum 100 mg/day

fluphenazine : 2.5 to 10 mg/day orally given in 3-4 divided doses initially, increase
gradually according to response, maximum 40 mg/day

trifluoperazine : 1-2 mg orally twice daily initially, increase gradually according to

response, maximum 40 mg/day

adjunct anxiolytic
Patients with symptoms of anxiety may benefit from the addition of an anxiolytic.
[56]

Studies have failed to demonstrate that buspirone is consistently effective against

panic attacks. [57] [58]

Primary Options

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alprazolam : 0.25 mg orally (immediate-release) three times daily initially, increase

gradually according to response, maximum 4 mg/day

clonazepam : 0.25 mg orally twice daily initially, increase gradually according to

response, maximum 4 mg/day

diazepam : 2-10 mg orally two to four times daily

buspirone : 7.5 mg orally twice daily initially, increase gradually according to

response, maximum 60 mg/day

plus psychosocial interventions

Psychosocial interventions are key components of long-term management. In order
for patients to comply with treatment and for treatment to be successful, issues
such as tenuous housing, low income, inadequate work skills, poor social support,
and restricted access to health care need to be overcome.
Intensive case management reduces hospitalization, improves adherence to care,
and improves social functioning. [60] Assertive community treatment, supported
employment, skills training, cognitive behavioral therapy, cognitive remediation,
token economy interventions, and family-based services are recommended. [53] [59]
Patient education about illness and medication fosters insight and compliance. [61]

Monitor for depressive symptoms and risk factors for suicide. Case management
should be implemented early in the illness process.
Family issues need to be addressed early because interventions are useful in relapse
prevention.
CBT is more efficacious in decreasing positive symptoms, and social skill training is
efficacious in decreasing negative symptoms. [64] [65]

plus general health maintenance

Schizoaffective disorder is associated with increased frequency of medical illnesses
and with a 15- to 20-year reduction in life expectancy. Managing the adverse
effects of medications is crucial because many of these agents further increase the
risk of medical illness. Health maintenance is, therefore, targeted to these adverse
effects.
Possible adverse effects include neurological adverse effects, metabolic
abnormalities (weight gain, blood glucose levels), hyperprolactinemia, cardiac
abnormalities, agranulocytosis, postural hypotension, and anticholinergic adverse
effects.

4th long-acting intramuscular antipsychotic

In patients with an extensive history of noncompliance, a long-acting intramuscular
antipsychotic should be considered.

Primary Options

risperidone : 25-50 mg intramuscularly (extended-release suspension) every 2

weeks

paliperidone : 234 mg intramuscularly (extended-release suspension) as a single

dose initially, followed by 156 mg one week later, then 117 mg once monthly
thereafter

olanzapine : 150-300 mg intramuscularly (extended-release suspension) every 2

weeks, or 405 mg every 2 weeks

adjunct anxiolytic
Patients with symptoms of anxiety may benefit from the addition of an anxiolytic.
[56]

Studies have failed to demonstrate that buspirone is consistently effective against

panic attacks. [57] [58]

Primary Options

alprazolam : 0.25 mg orally (immediate-release) three times daily initially, increase

gradually according to response, maximum 4 mg/day

clonazepam : 0.25 mg orally twice daily initially, increase gradually according to

response, maximum 4 mg/day

diazepam : 2-10 mg orally two to four times daily

buspirone : 7.5 mg orally twice daily initially, increase gradually according to

response, maximum 60 mg/day

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Schizoaffective disorder Treatment Options - Epocrates Online https://online.epocrates.com/dx/indexprint?entire=false&iid=...

plus psychosocial interventions

Psychosocial interventions are key components of long-term management. In order
for patients to comply with treatment and for treatment to be successful, issues
such as tenuous housing, low income, inadequate work skills, poor social support,
and restricted access to health care need to be overcome.
Intensive case management reduces hospitalization, improves adherence to care,
and improves social functioning. [60] Assertive community treatment, supported
employment, skills training, cognitive behavioral therapy, cognitive remediation,
token economy interventions, and family-based services are recommended. [53] [59]
Patient education about illness and medication fosters insight and compliance. [61]

Monitor for depressive symptoms and risk factors for suicide. Case management
should be implemented early in the illness process.
Family issues need to be addressed early because family are useful in relapse
prevention.
CBT is more efficacious in decreasing positive symptoms, and social skill training is
efficacious in decreasing negative symptoms. [64] [65]

plus general health maintenance

Schizoaffective disorder is associated with increased frequency of medical illnesses
and with a 15- to 20-year reduction in life expectancy. Managing the adverse
effects of medications is crucial because many of these agents further increase the
risk of medical illness. Health maintenance is, therefore, targeted to these adverse
effects.
Possible adverse effects include neurological adverse effects, metabolic
abnormalities (weight gain, blood glucose levels), hyperprolactinemia, cardiac
abnormalities, agranulocytosis, postural hypotension, and anticholinergic adverse
effects.

with depressive symptoms plus antidepressant

An antidepressant can be added to antipsychotic medication for patients who have
symptoms of depression associated with the illness.

Primary Options

fluoxetine : 20 mg orally once daily initially, increase gradually according to

response, maximum 80 mg/day

paroxetine : 20 mg orally once daily initially, increase gradually according to

response, maximum 50 mg/day

citalopram : 20 mg orally once daily initially, increase gradually according to

response, maximum 40 mg/day

sertraline : 50 mg orally once daily initially, increase gradually according to

response, maximum 200 mg/day

mirtazapine : 15 mg orally once daily initially, increase gradually according to

response, maximum 45 mg/day

with manic or mixed manic- plus mood stabilizer

depressive symptoms
A mood stabilizer can be added to antipsychotic medication for manic or mixed
symptoms associated with the illness.
Serum drug levels should be monitored - therapeutic levels can vary between
laboratories.

Primary Options

lithium : 300 mg orally (immediate-release) two to three times daily initially,

increase gradually according to response and serum drug level, maximum 2400
mg/day

carbamazepine : 200 mg orally (extended-release) twice daily initially, increase

gradually according to response and serum drug level, maximum 1600 mg/day

divalproex sodium : 250 mg orally (delayed-release) three times daily initially,

increase gradually according to response and serum drug level, maximum 60
mg/kg/day; 25 mg/kg orally (extended-release) once daily initially, increase
gradually according to response and serum drug level, maximum 60 mg/kg/day

lamotrigine : dose may depend on what drugs a patient is currently on; consult
specialist for guidance on dose

Referenced Articles

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Schizoaffective disorder Treatment Options - Epocrates Online https://online.epocrates.com/dx/indexprint?entire=false&iid=...

53 treatment recommendations 2009. Schizophr Bull. 2010;36:94-103.[Abstract]

http://www.ncbi.nlm.nih.gov/pubmed/19955388
[Full Text]
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800150/?tool=pubmed

51 Peuskens J. Good medical practice in antipsychotic pharmacotherapy. Int Clin Psychopharmacol. 1998;13(suppl 3):S35-
S41.[Abstract]
http://www.ncbi.nlm.nih.gov/pubmed/9690969

56 Gillies D, Sampson S, Beck A, et al. Benzodiazepines for psychosis-induced aggression or agitation. Cochrane Database Syst Rev.
2013;(9):CD003079.[Abstract]
http://www.ncbi.nlm.nih.gov/pubmed/24049046
[Full Text]
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003079.pub3/full

57 Cottraux J, Note ID, Cungi C, et al. A controlled study of cognitive behaviour therapy with buspirone or placebo in panic disorder
with agoraphobia. Br J Psychiatry. 1995;167:635-641.[Abstract]
http://www.ncbi.nlm.nih.gov/pubmed/8564320

58 Bouvard M, Mollard E, Guerin J, et al. Study and course of the psychological profile in 77 patients expressing panic disorder with
agoraphobia after cognitive behaviour therapy with or without buspirone. Psychother Psychosom. 1997;66:27-32.[Abstract]
http://www.ncbi.nlm.nih.gov/pubmed/8996712

60 Dieterich M, Irving CB, Park B, et al. Intensive case management for severe mental illness. Cochrane Database Syst Rev.
2010;(10):CD007906.[Abstract]
http://www.ncbi.nlm.nih.gov/pubmed/20927766
[Full Text]
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007906.pub2/abstract

59 Anaya C, Martinez Aran A, Ayuso-Mateos JL, et al. A systematic review of cognitive remediation for schizo-affective and affective
disorders. J Affect Disord. 2012;142:13-21.[Abstract]
http://www.ncbi.nlm.nih.gov/pubmed/22840620

61 Katschnig H. Rehabilitation in schizophrenia; guidelines for including psychosocial measures [in German]. Wien Med Wochenschr.
1998;148:273-280.[Abstract]
http://www.ncbi.nlm.nih.gov/pubmed/9746970

64 Turner DT, van der Gaag M, Karyotaki E, et al. Psychological interventions for psychosis: a meta-analysis of comparative outcome
studies. Am J Psychiatry. 2014;171:523-538.[Abstract]
http://www.ncbi.nlm.nih.gov/pubmed/24525715

65 Jauhar S, McKenna PJ, Radua J, et al. Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and
meta-analysis with examination of potential bias. Br J Psychiatry. 2014;204:20-29.[Abstract]
http://www.ncbi.nlm.nih.gov/pubmed/24385461

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