Treatment of schizophrenia, schizoaffective disorder

Schizophrenia

Schizophrenia is one of the 15 leading causes of disability worldwide. It is a chronic mental disorder in which affected individuals have a disturbance in thought process, perceptions, emotions and social interactions.1 Schizophrenia affects approximately 24 million people worldwide, or 1 in 300 people.2

Patients with schizophrenia have higher morbidity and mortality than the general population. Comorbidities such as diabetes, liver disease, and cardiovascular disease can contribute to premature death. Concomitant medical conditions are higher in this patient population and are generally undertreated, contributing to the higher mortality rate.1

Symptoms

Symptoms of schizophrenia include positive symptoms, which are the presence of certain characteristics, and negative symptoms, which are the absence of normal behaviors and functions, such as decreased speech and/or cognitive impairment. Typically, negative symptoms and cognitive impairment appear years before positive symptoms and account for much of the long-term disability and poor functional outcomes.

Positive symptoms of schizophrenia

  • Hallucinations (visual, auditory, tactile)
  • Delusions
  • Paranoia
  • Disorganized speech (eg, frequent derailments or incoherence)

Negative symptoms of schizophrenia

  • Social withdrawal
  • Anhedonia (inability to feel or express pleasure)
  • Avolition (lack of motivation or ability to perform useful tasks)
  • flat effect
  • Alogy (poverty of speech/diminished verbal expression)
  • Apathy (lack of interest or emotion)

Patients with schizophrenia may lack the ability to function normally in society, with poor hygiene and routine personal care. Therefore, schizophrenia can lead patients to be unable to maintain full-time employment and to have problems in their interpersonal relationships and social life. Patients with schizophrenia may experience communication problems, having trouble putting meaningful words together.3.4

Cognitive impairment

  • Attention deficits.
  • Poor verbal and learning memory.
  • Reduced processing speed.
  • Deficits in executive functions.
  • Lower IQ.

Social and professional dysfunction

  • Low level of functioning in work, interpersonal relationships and self-care.

Patients are usually diagnosed in their teens to early thirties. Symptoms tend to appear earlier in men than in women.1

Schizoaffective disorder

Similar to schizophrenia, schizoaffective disorder is a chronic disabling mental disorder. It’s a combination of schizophrenia symptoms and mood symptoms. There are 2 types of schizoaffective disorder:5.6

  • Bipolar schizoaffective disorder
  • Schizoaffective disorder of the depressive type

Bipolar type patients experience both manic and depressive episodes, while depressive type patients only experience depression but not mania. During the manic phase, patients experience high energy, grandeur (exaggerated self-importance, knowledge and abilities), racing thoughts, increased risky behavior, pressured speech, and no or little sleep while feeling rests.

Schizoaffective disorder is relatively rare (lifetime prevalence of 0.3%). Similar to schizophrenia, men develop the disease at an earlier age than women. Many patients with schizoaffective disorder may be misdiagnosed as bipolar disorder or schizophrenia.5

Etiology

The etiology of schizophrenia and schizoaffective disorders is not well understood; however, genetics, brain chemistry/structure (imbalance of neurotransmitters), stressful life events/trauma, and illicit drug use may contribute to the development of schizophrenia/schizoaffective disorder.5

Treatment

The mainstay of treatment for schizophrenia and schizoaffective disorder includes antipsychotics.seven This class of drugs helps reduce hallucinations, delusions, and paranoia.

Additionally, antipsychotics help with mood changes associated with schizoaffective disorder. Second generation antipsychotics are preferred over first generation antipsychotics due to better tolerability and adverse effect profile.

First-generation antipsychotics (typical antipsychotics)

  • Haloperidol (Haldol)
  • Fluphenazine (Prolixin)
  • Chlorpromazine (Thorazine)
  • Perphenazine (Trilafon)

Second-generation antipsychotics (atypical antipsychotics)

  • Aripiprazole (Abilify)
  • Quetiapine (Seroquel)
  • Olanzapine (Zyprexa)
  • Risperidone (Risperdal)
  • Ziprasidone (Geodon)
  • Lurasidone (Latuda)
  • Asenapine (Saphris)
  • Brexpiprazole (Rexulti)
  • Cariprazine (Vraylar)
  • Iloperidone (Fanapt)
  • Clozapine (Clozaril, Versacloz)
  • Paliperidone (Invega)
  • Lumateperone (Caplyta)

In addition to oral formulations, some of the above medications are also available as long-acting injectables (LAI). Most LAIs are monthly injections given intramuscularly. However, some are available to be administered less frequently, such as every 3 months or every 6 months. LAIs are suitable for patients who have poor adherence to their antipsychotics and/or who prefer less frequent administration of medication. The use of LAIs may reduce the pill burden for patients.

LAI2

  • Fluphenazine (Polixin): Dosage every 2 weeks.
  • Haloperidol Econate (Haldol Deconate): Dosage every 4 weeks.
  • Aripiprazole (Abilify Maintena, Aristada): Dosage every 4 weeks.
  • Paliperidone palmitate (Invega Sustena, Invega Trinza, Invega Hafyera): Dosing every 4 weeks, every 3 months, every 6 months, respectively.
  • Risperidone (Risperdal Consta, Perseris): Dosing every 2 weeks, every 4 weeks, respectively.

Besides antipsychotics, patients with schizoaffective disorder may need additional medications to treat the mood component of the illness depending on the type of schizoaffective disorder. Patients are commonly prescribed mood stabilizers, such as valproic acid, and antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin and hormone reuptake inhibitors. norepinephrine (SNRI).

mood stabilizers

  • Valproic Acid (Depakote)
  • Lithium (Lithobide, Eskalith)
  • Lamotrigine (Lamictal)
  • Carbamazepine (Tegretol)
  • Oxcarbazepine (Trileptal)
  • Topiramate (Topamax)

Antidepressants

  • SSRIs
    • Fluoxetine (Prozac)
    • Sertraline (Zoloft)
    • Citalopram (Celexa)
    • Escitalopram (Lexapro)
    • Paroxetine (Paxil)
    • Fluvoxamine (Luvox)
  • NRIS
    • Venlafaxine (Effexor)
    • Duloxetine (Cymbalta)
    • Vortioxetine (Trintellix)
    • Vilazodone (Viibryd)
    • Desvenlafaxine (Pristiq)
  • Others
    • Mirtazapine (Remeron)
    • Bupropion (Wellbutrin)

In conclusion, schizophrenia and schizoaffective disorder are chronic disabling mental disorders characterized by positive symptoms, such as hallucinations, delusions and paranoia. Schizoaffective disorder has additional mood symptoms, such as depression and bipolar symptoms.

Drug therapy is the cornerstone of treatment for schizophrenia and schizoaffective disorder. Basic treatment includes antipsychotics, mood stabilizers and antidepressants. Treatment with antipsychotics can help improve quality of life and social functioning.

References

  1. Schizophrenia, 2022. National Institute of Mental Health (NIMH). 2022. Schizophrenia. [online] https://www.nimh.nih.gov/health/statistics/schizophrenia#:~:text=Across%20studies%20that%20use%20household,between%200.25%25%20and%200.64%25. Accessed September 6, 2022.
  2. Schizophrenia, 2022. Who.int. 2022. Schizophrenia. [online]. https://www.who.int/news-room/fact-sheets/detail/schizophrenia#:~:text=Schizophrenia%20affects%20approximately%2024%20million,%25)%20among%20adults%20(2). Accessed September 6, 2022.
  3. Schizophrenia – Symptoms and causes. Mayo Clinic. 2022. Schizophrenia – Symptoms and Causes. [online] https://www.mayoclinic.org/diseases-conditions/schizophrenia/symptoms-causes/syc-20354443. Accessed September 6, 2022.
  4. Bowie CR, Harvey PD. Cognitive deficits and functional outcomes in schizophrenia. Treat neuropsychiatric diseases. 2006 Dec;2(4):531-6. doi: 10.2147/nedt.2006.2.4.531. PMID: 19412501; PMCID: PMC2671937.
  5. Schizoaffective disorder. NAMI: National Alliance on Mental Illness, 2022. Nami.org. 2022. Schizoaffective Disorder | NAMI: National Alliance on Mental Illness. [online]. https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Schizoaffective-Disorder. Accessed September 6, 2022.
  6. Schizoaffective Disorder – Symptoms and Causes, 2022. Mayo Clinic. 2022. Schizoaffective Disorder – Symptoms and Causes. [online] https://www.mayoclinic.org/diseases-conditions/schizoaffective-disorder/symptoms-causes/syc-20354504#:~:text=Schizoaffective%20disorder%20is%20a%20mental,such%20as%20depression%20or%20mania .Accessed September 6, 2022.
  7. Goalkeepers GA, Fochtmann LJ, Anzia JM, Benjamin S, Lyness JM, Mojtabai R, Servis M, Walaszek A, Buckley P, Lenzenweger MF, Young AS, Degenhardt A, Hong SH; (Systematic review). American Psychiatric Association practice guidelines for the treatment of patients with schizophrenia. Am J Psychiatry. 2020 Sep 1;177(9):868-872. doi: 10.1176/appi.ajp.2020.177901. PMID: 32867516.

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