What is the treatment approach for schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)?

Treatment Approach for Schizophrenia According to DSM-5

The cornerstone of schizophrenia treatment is antipsychotic medication combined with psychosocial interventions, with medication selection based on individual side effect profiles and symptom presentation. 1

Pharmacological Management

Initial Treatment

• Antipsychotic treatment should be offered to individuals who have experienced a week or more of psychotic symptoms with associated distress or functional impairment 1
• Earlier initiation is appropriate when symptoms cause severe distress or pose safety concerns to self or others 1
• Initial antipsychotic choice should be made collaboratively with the patient based on side-effect and efficacy profiles 1
• First antipsychotic medication should be given at a therapeutic dose for at least 4 weeks to properly assess efficacy 1

Treatment Algorithm for Positive Symptoms

• If significant positive symptoms persist after 4 weeks of good adherence at therapeutic dose, switch to an alternative antipsychotic with a different pharmacodynamic profile 1
• First-generation and second-generation antipsychotics should not be considered distinct categories when guiding medication choice 1
• For patients whose first-line treatment was a D2 partial agonist (like aripiprazole), consider amisulpride, risperidone, paliperidone, or olanzapine as second-line options 1
• Antipsychotic switching should involve gradual cross-titration informed by the half-life and receptor profile of each medication 1

Treatment-Resistant Schizophrenia

• If positive symptoms remain significant following a second treatment for at least 4 weeks at therapeutic dose with good adherence, reassess diagnosis and potential contributing factors 1
• For confirmed treatment-resistant schizophrenia, clozapine should be initiated 1
• Metformin should be offered concomitantly with clozapine to attenuate potential weight gain 1
• Clozapine dose should be titrated based on therapeutic response and tolerability, aiming for a plasma level of at least 350 ng/mL 1
• For persistent symptoms despite adequate clozapine trial, consider augmentation with amisulpride, aripiprazole, or electroconvulsive therapy 1

Special Considerations

• Long-acting injectable antipsychotics should be considered for patients who prefer this option or have a history of poor/uncertain adherence 1
• Clozapine is specifically recommended for patients with substantial suicide risk despite other treatments 1
• For aggressive behavior that remains substantial despite other treatments, clozapine should be considered 1

Management of Medication Side Effects

• For acute dystonia associated with antipsychotic therapy, treat with an anticholinergic medication 1
• For parkinsonism, consider lowering the antipsychotic dose, switching to another antipsychotic, or treating with an anticholinergic medication 1
• For akathisia, options include lowering the dose, switching to another antipsychotic, adding a benzodiazepine, or adding a beta-adrenergic blocking agent 1
• For moderate to severe tardive dyskinesia, treatment with a reversible inhibitor of the vesicular monoamine transporter 2 (VMAT2) is recommended 1

Psychosocial Interventions

• Patients experiencing first-episode psychosis should be treated in a coordinated specialty care program 1, 2
• Cognitive-behavioral therapy for psychosis (CBTp) is recommended for all patients 1, 2
• All patients should receive psychoeducation about their illness 1, 2
• Supported employment services should be provided to improve functional outcomes 1, 2
• Assertive community treatment is recommended for patients with a history of poor engagement with services leading to frequent relapse or social disruption 1
• Family interventions should be offered to patients who have ongoing contact with family 1
• Interventions aimed at developing self-management skills and enhancing person-oriented recovery should be considered 1

Monitoring and Follow-up

• Regular monitoring of antipsychotic effectiveness and side effects, particularly metabolic parameters (weight, glucose, lipids) is essential 2
• Monitor for early signs of relapse and adjust treatment accordingly 2
• Regular physical health monitoring is crucial as patients with schizophrenia have higher rates of physical comorbidities and mortality 2
• Assess and manage suicide risk, particularly in males early in the course of the disorder 2

Common Pitfalls to Avoid

• Avoid antipsychotic polypharmacy except after a failed clozapine trial 2
• Don't overlook negative symptoms when focusing on positive symptoms 2
• Avoid inadequate duration of treatment trials (less than 4 weeks at therapeutic dose) 1
• Don't neglect physical health monitoring and interventions 2
• Avoid dismissing clozapine as an option for treatment-resistant cases due to monitoring requirements 1