Schizophrenia

Introduction

Schizophrenia is a serious psychotic disorder characterized by multiple impairments in emotional, behavioural, cognitive, social, and occupational domains (among others). It affects about 1% of the population.
Onset usually in late adolescence or early adulthood.
It has a strong genetic component to its etiology; environmental factors, including pre-natal and obstetric factors, also implicated Clinical features
Schizophrenia is a disorders of:

  • Perception
  • Speech
  • Thought
  • Motor function.
  • Cognition
  • Behaviour

Differential diagnoses

  • Psychosis of other origin (including those due to organic factors)
  • Epilepsy, especially of temporal lobe origin
  • Drug effect, e.g. amphetamine intoxication
  • Affective psychosis

Complications

  • Chronicity
  • Increased physical morbidity
  • Suicide
  • Increased mortality

Investigations

  • To exclude organic causes of acute psychotic presentations

Treatment objectives

  • Relieve acute symptoms
  • Return to full functional status
  • Rehabilitate
  • Prevent relapse

Non-drug treatment

  • Psycho-social interventions as indicated (including social and occupational therapy)
  • Psycho-education for patient and relatives / caregivers

Supportive psychotherapy

  • ECT (especially for catatonic forms)

Drug treatment

1st Line Treatment
Evidence Rating: [A]

A. Management of acute attacks

Olanzapine, IM or oral,
Adults: 5-10 mg stat. Then 5-10 mg daily, max. 20 mg daily
Children .

  • > 12 years; 5-10 mg stat. Then 5-10 mg daily, max. 20 mg daily
  • < 12 years; Not recommended

Or

Chlorpromazine, IM,
Adults: 25-50 mg 6-8 hourly, adjusting to max. of 400 mg daily
Children:

  • 12-18 year; 25-50 mg 6-8 hourly, adjusting to max. of 400 mg daily¬† 6-12 years; 500 microgram/kg 6-8 hourly to max. of 75 mg daily
  • 1-6 year; 500 microgram/kg 6-8 hourly to max. of 40 mg daily

Or

Chlorpromazine, oral,
Adults: 25 mg 8 hourly or 75 mg at night, Then Adjust according to response to 75-300 mg daily
Children

  • > 12 years; 25 mg 8 hourly or 75 mg at night, Then Adjust according to response to max. of 75-300 mg daily
  • 6-12 years; 10 mg 8 hourly, Then Adjust according to response to max. of 75 mg daily
  • 1-6 years; 500 microgram/kg 4-6 hourly, Then Adjust according to response to max. of 40 mg daily

Or

Haloperidol, IM,
Adults: 2-5 mg stat. Then Repeat 4-8 hourly according to response, to maximum of 20 mg daily
Children

  • 6-12 years; 1-3 mg 4-8 hourly as required
  • < 6 years; Not recommended

Or

Haloperidol, oral,
Adults: 0.5-5 mg 8-12 hourly daily Then 5-10 mg 8-12 hourly (max. of 30 mg)
Children

  • > 12 years; 0.5-5 mg 8-12 hourly daily, Then 5-10 mg 8-12 hourly (max. of 30 mg)
  • 3-12 years or body weight 15-40 kg; 0.25-0.5 mg daily Then increase by 0.5 mg daily every 5-7 days
  • < 3 years; Not recommended

B. Maintenance

Risperidone, oral,
Adults: 1-4 mg 12-24 hourly (start at low dose and adjust daily according to patient response)

Or

Olanzapine, oral,
Adults: 5-10 mg, max. 20 mg daily
Children

  • > 12 years; 5-10 mg, max. 20 mg daily
  • < 12 years; Not recommended

Or

Chlorpromazine, oral,
Adults: 25 mg 8 houly or 75 mg at night, adjust to max. of 200 mg 8 hourly
Children:

  • 12-18 years; 25 mg 8 hourly or 75 mg at night, adjust to max. of 200 mg 8 hourly
  • < 12 years; Not recommended

Or

Haloperidol, oral,
Adults: 1-3 mg 8 hourly, adjusted to max. daily dose of 20 mg
Children:

  • 12-18 years; 1-3 mg 8hourly, adjusted to max. daily dose of 20 mg
  • 3-12 years; 500 micrograms 12 hourly, adjust up to a max. of 5 mg 12 hourly

C. Maintenance treatment for patients with recurrent or chronic illness (depot preparations)

Fluphenazine decanoate, IM,
Adults: 25 mg monthly
Children: Not recommended

Or

Flupenthixol decanoate, IM,
Adults: Give test dose of 5-20 mg, and after at least 7 days, give 40 mg monthly
Children: Not recommended

D. Adjunct treatment for management or prevention of antipsychotic drug side effects

Trihexyphenidyl (Benzhexol), oral,
Adults: 2.5-5 mg 6-8 hourly max. 20 mg daily
Children:
6-18 years; 0.5-1 mg 12-24 hourly, Then increase every 3-7 days by 1 mg daily according to response

Or

Benzatropine (Benztropine), oral,
Adults: 1-2 mg 8-12 hourly
Children

  • >3 years; 20-50 microgram/kg 12-24 hourly

Or

Biperidine, oral,
Adults: 1 mg 12 hourly, Then adjust to 2 mg 8 hourly up to 4 mg 8 hourly.
Children: Not recommended

Or

Biperidine, slow IV/IM,
Adults: 2.5-5 mg adjust to a max. of 20 mg in 24 hours

Or

Benztropine, IV/IM,
Adults: 1-2 mg slowly over 2-4 minutes, repeat if symptoms persist after 8-12 hours.

Or

Diazepam, oral,
Adults: 5-10 mg 6-12 hourly
Children:

  • 12-18 years; 10 mg 12 hourly
  • 5-12 years; 5 mg 12 hourly

Or

Diazepam, IV,
Adults: 5-10 mg slowly over 2-3 minutes (approximately 2.5 mg every 30 seconds)
Children: 200-300 microgram/kg slowly over 2-3 minutes. This may be repeated 10 minutes.

Or

Promethazine hydrochloride, oral or IM,
Adults 12.5-25 mg initially, may repeat dose if symptoms persist after 6 hours
Children
6.25-12.5 mg

  • > 6 years; 6.25-12.5 mg Then Repeat dose after 6 hours
  • < 6 years; Not recommended

Supportive measures

  • Supportive psychotherapy
  • Social and occupational therapy
  • Cognitive therapy (as adjunct in the treatment of persisting psychotic experience)
  • Rehabilitation

Notable adverse drug reactions

  • Extrapyramidal and Parkinsonian
    symptoms (may require anticholinergic medication)
  • Tardive dyskinesia
  • Weight gain
  • Agranulocytosis (monitor blood counts in patients on clozapine)

Prevention

  • No clear/specific scope for primary
    prevention at present
  • Secondary and tertiary:
    • Early and effective treatment
  • Rehabilitation to reduce disability.

Referral Criteria

Refer all patients to a psychiatrist after an acute episode of treatment