Schizophrenia

Clinical Description

To diagnose schizophrenia there must be at least a six month history of impairment and disability and within the six months period, at least a month (or less if the symptoms have been successfully treated)

Signs and Symptoms

• history of the symptoms listed below.
• Hallucinations (often auditory) and delusions (fixed false belief)
• Speech can be irrelevant and incoherent
• Disorganized thought / behaviour
• Lack of insight is prominent

Investigations

• In a first episode of psychotic symptoms, physical causes for the symptoms must be excluded e.g delirium, thyroid dysfunction, syphilis, HIV)
• Full physical examination
• FBC
• VDRL
• Urine drug screen if available

Treatment

PITC Treatment

• Treatment is both pharmacological and psychological (supportive counselling about the illness, compliance with medication, education to the guardians
• The aim of treatment is to remove all symptoms if possible and to help the person to return to their previous level of functioning

Primary treatment

• First line commences an anti-psychotic medication which will need to be continued for at least two years if this is a first episode or for a minimum of five years if the person has had two episodes. If the person has had three or more episodes without clear precipitants (e.g., substance use, psychosocial stressors) antipsychotics should be continued for life
• Give Chlorpromazine 100 mg nocte or Haloperidol 2.5mg nocte. Increase dose weekly/ two weekly depending on patient response and side effects to a maximum of Chlorpromazine 300mg nocte or Haloperidol 5mg nocte.
• Always start the antipsychotic at the lowest effective dose and prescribe as a single daily dose
• All anti-psychotic medication ha a delayed onset of action - advice the patient/ guardian it will take 1-2 weeks before improvement is noted
• Antipsychotics should be prescribed as monotherapy (only one antipsychotic should be used at one time)
• Advise about the side effects:
• Chlorpromazine: sedation, postural hypotension, constipation, photosensitivity, sexual side effects
• Haloperidol: Extra-pyramidal side effects (parkinsonism symptoms), stiffness of limbs/jaw, eyes rolling upwards, restlessness, drowsiness, salivation, sexual side effects
• Patients should be advised to report to the hospital immediately if they develop stiffness of limbs/jaw and abnormal eye movements
• If EPSEs persist consider reducing the dose of anti- psychotic or adding Benzhexol 5mg daily until side effects resolve.
• Use lower doses of antipsychotics in patients with HIV, epilepsy and intellectual disability
• Secondary /alternative treatment
• If symptoms have not improved on chlorpromazine/haloperidol or if the person has lots of side effects use a second-generation anti-psychotic

Risperidone 1mg nocte 2 days then increase to 2mg nocte. Increase weekly/two weekly by 1mg to a maximum dose of 6mg nocte depending on patient response or side effects.

Advice about side effects:

Risperidone: weight gain, sedation, impaired glucose tolerance, sexual side effects

• If compliance with medication is poor despite trying to reduce side effects and counselling on the importance of compliance with medication, consider a long-acting depot anti- psychotic Fluphenazine 12.5mg IM into a large muscle e.g. gluteal/ deltoid) as a test dose
• Caution: risk of Acute Dystonic reaction (painful spasm of head and neck muscles)
• If occurs give Benzhexol po if able to swallow
• Otherwise, IV/IM Procyclidine or Benzhexol 5mg OR slow IV push Diazepam 5-10mg
• Advice about side effects: EPSE
• Maintenance dose Fluphenazine 25mg every 4 weeks which can be increased to 50mg every 4 weeks IM after a 3-month interval

Red Flags

• For referral
• If EPSE persist, consider reducing the dose or stop the Fluphenazine
• If symptoms persist/ worsen despite 6-8 weeks of anti-psychotic medication at an effective dose
• If side effects are not manageable
• If the person has Catatonic symptoms
• If the patient has been treated with two different antipsychotics (one first generation and one second generation) at adequate doses for longer than three months on each but psychotic symptoms or functional impairment persists.
• If the patient develops tardive dyskinesia (abnormal facial movements – chewing, grimacing or chorea-like trunk movements) on antipsychotics
• For admission
• Marked agitation / aggression should be managed as an inpatient following the Violence and Aggression treatment guidelines
• Evidence of dehydration and malnutrition due to prolonged poor self-care
• Evidence that the patient is a risk to themselves (self-harm/ neglect/ vulnerable to exploitation) or a risk to others (agitation/ aggression)
• If insight is lacking and there is no guardian to ensure compliance with medication at home

Treatment duration

• • When considering stopping medication, discuss carefully with the patient and guardian and start to reduce slowly over 4-8 weeks
• • Advise about symptoms that would indicate relapse (difficulty sleeping, auditory hallucinations, suspicious thoughts) and inform to return to the clinic promptly. Continue to monitor until medication free for 2-3 months before discharging
• • Advise them to return to the clinic for review if have any concerns in the future

Follow-up

Note: Neuroleptic Malignant Syndrome is a severe but rare complication of anti-psychotics, presenting with fever, rigidity, fluctuating pulse and BP and reduced conscious level. It is a medical emergency. All anti-psychotics should be stopped, and the person referred for medical admission.

• Screen for ongoing symptoms and monitor for side effects at each review
• Adjust the dose of medication accordingly
• Ask about any drug or alcohol use and give advice about use
• Screen for low mood and suicidal ideation at each review and follow Depression

Treatment Guideline if present

• Once symptoms are improving advice the patient to return to their usual daily activities, including work if employed