What is the recommended treatment for schizophrenia?

Treatment of Schizophrenia

The recommended first-line treatment for schizophrenia is antipsychotic monotherapy, which should be initiated for individuals experiencing psychotic symptoms for a week or more with associated distress or functional impairment. 1, 2

Initial Treatment Approach

First-Line Pharmacotherapy

• Antipsychotic medication should be offered to individuals who have experienced psychotic symptoms for ≥1 week with distress or functional impairment
• Earlier initiation is appropriate for severe distress or safety concerns
• Initial choice should be made collaboratively with the patient based on side-effect and efficacy profiles
• First antipsychotic should be given at therapeutic dose for at least 4 weeks before considering changes 1

Dosing Considerations

• For olanzapine: Start with 5-10mg daily, with target dose of 10mg/day within several days 3
• For risperidone: Typically start at lower doses and titrate based on response and tolerability 4
• Monitor closely during initial titration period

Treatment Algorithm for Inadequate Response

1. First antipsychotic trial: Give therapeutic dose for at least 4 weeks
2. If inadequate response: Switch to a different antipsychotic with different pharmacodynamic profile
   • For patients whose first-line was a D2 partial agonist, consider amisulpride, risperidone, paliperidone, or olanzapine (with metformin) 1
   • Use gradual cross-titration when switching medications
3. If second antipsychotic fails: After 4-week trial at therapeutic dose with good adherence:
   • Reassess diagnosis and contributing factors (organic illness, substance use)
   • If schizophrenia diagnosis confirmed, trial clozapine 1, 2
4. Clozapine management:
   • Offer metformin concomitantly to attenuate weight gain
   • Titrate dose based on therapeutic response and tolerability
   • Aim for plasma level of at least 350 ng/mL
   • If symptoms persist after 12 weeks, may increase to plasma concentration up to 550 ng/mL 1
5. For clozapine-resistant cases: Consider augmentation with amisulpride, aripiprazole, or electroconvulsive therapy 1

Management of Specific Symptom Domains

Positive Symptoms

• Antipsychotic medications are the cornerstone of treatment
• Monitor response after 4 weeks of therapeutic dosing
• Consider clozapine after failure of two adequate antipsychotic trials 1, 2

Negative Symptoms

• Address secondary causes: persistent positive symptoms, depression, substance misuse, social isolation, medication side effects
• Offer psychosocial interventions to address psychological factors and encourage social engagement
• Consider clozapine augmentation with an antidepressant for persistent negative symptoms 1

Psychosocial Interventions

Implement concurrently with medication:

• Cognitive-behavioral therapy for psychosis
• Psychoeducation for patient and family
• Supported employment/education services
• Social skills training
• Coordinated specialty care programs for first-episode psychosis 2

Monitoring and Side Effect Management

Initial Baseline Assessment

Before starting antipsychotic treatment, obtain:

• BMI, waist circumference, blood pressure
• HbA1c, glucose, lipids, prolactin
• Liver function tests, urea and electrolytes
• Full blood count
• Electrocardiogram 1

Follow-up Monitoring

• Fasting glucose: Re-check 4 weeks after initiation
• BMI, waist circumference, blood pressure: Check weekly for 6 weeks
• All measures repeated after 3 months and annually thereafter 1

Managing Common Side Effects

Metabolic Effects

• Olanzapine causes more weight gain than most other antipsychotics 5, 6, 7
• Strategies for metabolic side effects:
  • Consider switching to an antipsychotic with better metabolic profile
  • Add metformin for weight management
  • Lifestyle interventions (diet, physical activity) 1

Extrapyramidal Symptoms

• Olanzapine generally has fewer extrapyramidal side effects than risperidone 5, 6
• For akathisia: Consider dose reduction or switch to quetiapine/olanzapine 1
• For acute dystonia: Consider anticholinergic medication 2

Hyperprolactinemia

• More common with risperidone than olanzapine 5, 6
• For symptomatic hyperprolactinemia: Consider switching to a D2 partial agonist 1

Common Pitfalls to Avoid

• Inadequate duration of antipsychotic trials (minimum 4 weeks needed)
• Failure to monitor for metabolic and neurological side effects
• Premature discontinuation after symptom resolution
• Neglecting psychosocial interventions
• Overlooking treatment of comorbid substance use disorders
• Failure to recognize and address treatment resistance promptly 2
• Using antipsychotic polypharmacy before trying clozapine 2

Special Considerations

• For adolescents (13-17 years): Consider increased risk of weight gain and dyslipidemia with olanzapine compared to adults 3
• For patients with poor adherence: Consider long-acting injectable antipsychotics 2
• For substance use comorbidities: Use non-judgmental approach and co-work with specialist substance use services 1