DSM-5 Criteria for Schizophrenia
2 or more of the following persisting for at least 1 month: At least one of the symptoms must be (1), (2), or (3): • Delusions • Hallucinations • Disorganized Speech • Disorganized or catatonic behavior • Negative symptoms
Other things to look for when diagnosis Schizo
Level of social and/or occupational functioning has significantly declined
Continuous signs for at least 6 months. May include prodromal or residual symptoms
Schizoaffective or mood disorder has been excluded
Disorder not due to a medical disorder or substance abuse
If a development disorder is present, there must be symptoms of hallucinations/delusions for at least 1 month
Acute Stabilization Treatment
Initiate antipsychotic treatment and titrate the dose every few days
If “cheeking” use liquid or orally disintegrating tablets
For severely agitate patients, consider quick actin antipsychotic by IM injection
Chemical restraining is recommended over physical
During the first 7 days pf acute stabilization, you should see:
decreased agitation, hostility, anxiety, and aggression & sleep and appetite should improve
Define cheeking
When a patient appears to be taking his medication, but instead places the pill inside of his cheek and spit sit out when no one is looking
Stabilization Treatment
Takes 6 weeks or longer
If no improvement is seen within 3-4 weeks or only a partial decrease in positive symptoms is observed within 12 weeks with therapeutic doses then the next treatment algorithm stage should be considered.
Continue increasing the antipsychotic dose gradually for more symptom control if tolerated.
Goal of treatment:
Achieve no or minimal positive symptoms
Negative/cognitive symptoms are less likely to remit even with appropriate treatment
Maintenance Treatment
Continued treatment with antipsychotic therapy is recommended to prevent future relapses
At least 5 years but lifetime for chronically ill
For patients experiencing their first psychotic episode –
A first or second generation antipsychotic other than clozapine or olanzapine is recommended.
• If the first agent is not effective, then switch to another first or second generation antipsychotic other than clozapine. Olanzapine can be considered as an option at this stage.
For patients who have experienced more than 1 psychotic episode but they have been treatment responsive in the past-
- A first or second generation antipsychotic other than clozapine is recommended.
- If the first agent is not effective, then switch to another first or second generation antipsychotic other than clozapine.
For treatment resistant patients
- Clozapine is the recommended antipsychotic for treatment resistant patients.
- Clozapine can be offered sooner for patients with violent behaviors or suicidality.
Define Treatment Resistant
Failing 2 or more antipsychotic trials where the antipsychotic were dosed appropriately and given for an appropriate amount of time
***Class 1 Antipsychotics
Chlorpromazine Thioridazine Loxapine Perphenazine Thiothixene Haloperidol Fluphenazine
Chlorpromazine and Thioridazine have
low EPS and high metabolic side effects (anti-cholinergic, sedation/weight gain, low BP)
Loxapine, perphenazine, thiothixene, haloperidol and fluphenazine all have
HIGH EPS but low metabolic side effects
2nd Generation Antipsychotics
THE “PINES” Clozapine Olanzapine Quetiapine Asenapine THE “DONES” Risperidone Paliperidone Ziprasidone Iloperidone Lurasidone THE D2 PARTIAL AGONISTS (THE “PIPS”) Aripiprazole Brexpiprazole
The Pines all show
Low EPS
Ziprasidone shows
Low side effects overall
Illoperidone shows
Low EPS
Risperidone, Paliperidone, Lurasidone show
High EPS
The PIPs show
Low everything but Aripiprazole has akathisia while brexpiprazole does not
Weight Monitoring
Baseline then every month for 3 months and then every 3 months
Waist Circumference Monitoring
Baseline and annually
Blood pressure and FPG monitoring
Baseline then 12 weeks then annually
FLP Monitoring
Baseline then 12 weeks then every 1-5 years
Clozapine Counseling and Monitoring
o May take daily dose once daily at bedtime or may divide dose into BID dosing
o Dose must be started low and titrated gradually to avoid orthostatic hypotension. If doses are missed > 3 days then the patient needs to restart the dosing titration
o If patient becomes neutropenic (ANC
Define Parkinsonism
- Patient may experience muscle rigidity, tremor, bradykinesia, and postural instability
- 1-2 weeks after the antipsychotic is started or after a dose increase
Treatment of Parkinsonism
Anticholinergics (benztropin, diphenhydramine, trihexphenidyl)
Define Dystonia
Dystonia is tonic muscle contractions. These contractions often occur in the neck and shoulder muscles
• 1-4 days after the antipsychotic is started or after a dose increase.
Dystonia Treatment
Anticholinergics
Akathisia
Akathisia is a constant feeling of inner restlessness. The patient may pace back and forth, shift constantly in their seat, seen tapping their feet
Treatment of Akathisia
It is recommended to reduce the antipsychotic dose or use a different agent. Propranolol may be effective in reducing akathisia in some patients
Define Tardive Dyskinesia
• Tardive dyskinesia is involuntary movements of the muscles. Usually the facial muscles are affected (sticking out tongue, puckering lips, lip smacking, grimacing) but it can also be observed in the extremities and truncal area in severe cases
Treatment of Tardive Dyskinesia
Recommended to decrease and/or discontinue the antipsychotic and switch to an agent that has less dopamine antagonism. Symptoms will appear to worsen at first, followed by slow improvement
Define AIMS
Abnormal Involuntary Movement Scale
Clinicians should administer the scale at baseline before a new antipsychotic is started and every 3-6 months after
Observing any abnormal movements
Haloperidol
First Generation Antipsychotics
1A2
Monitor: EKG
Counsel: May take daily dose once at bedtime or divide into BID
Fluphenazine
First Generation Antipsychotics
2D6
Monitor: EKG, CBC, BP
Counsel: May take daily dose once at bedtime or divide into BID
Perphenazine
First Generation Antipsychotics
2D6
Monitor: EKG, CBC, BP
Counsel: BID or TID
Loxapine
First Generation Antipsychotics
1A2
Monitor: EKG, BP
Counsel: May take daily dose once at bedtime or divide into BID
Clozapine
Second Generation
1A2
Monitor: HR, BP, Constipation
Counsel: May take daily dose once at bedtime or divide into BID
Olanzapine
Second generation
1A2
Monitor: CBC and metabolic
Counsel: QHS
Risperidone
Second generation
2D6
Monitor: BP and metabolic
Counsel: May take daily dose once at bedtime or divide into BID
Paliperidone
Second generation
No CYP
Monitor: BP and metabolic
Counsel: QHS
Quetiapine
Second Generation
3A4
Monitor: BP and metabolic
Counsel: ER- QHS, IR- BID to TID
Ziprasidone
Second Generation
3A4
Monitor: EKG
Counsel: BID, take with 500 calorie meal
Aripiprazole
Second generation
2D6 and 3A4
Monitor: AIMS only
Counsel: QAM
Iloperidone
Second generation
3A4 and 2D6
Monitor: BP, EKG, metabolic
Counsel: BID
Asenapine
Second Generation
1A2
Monitor: EKG and metabolic
Counsel: BID sublingual
Lurasidone
Second generation
3A4
Monitor: AIMS only
Counsel: QD with evening 500 calorie meal
Brexipirazole
Second generation 3A4 and 2D6 Monitor: AIMS only COunsel QAM
Aripiprazole IM
Abilify Maintena
400 mg → given once monthly – 14 day overlap
Haloperidol IM
Haldol D
10-15 X → given once monthly – 1 month overlap
Paliperidone IM
Invega Sustenna
234 mg → 156 mg → given once monthly – no overlap
Olanzapine IM
Zyprexa Relprevv
Q2 wks x 4 doses → given once/twice monthly – none listed
Risperidone IM
Risperdal Consta
given every 2 weeks – 3 week overlap
Fluphenazine IM
Prolixin D
1.2 X → given weekly for 4-6 wks then every 3-6 weeks- 1 week overlap
CATIE/CUtLASS Study
The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study and the Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS) showed no difference between second generation and first generation antipsychotics when comparing clinical outcomes such as time to discontinuation and quality of life. Both studies were federally funded.