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For further details see Mental Health Prescribing Forum Prescribing Guideline PG10 Pharmacological Treatment of Schizophrenia and Related Psychoses
These guidelines cover the management of schizophrenia. However, a diagnosis of schizophrenia is often made over a period of time so the 'Initial psychotic episode' guidance applies to pharmacologically treating brief psychotic episodes including drug-induced psychosis.
Psychological and psychosocial interventions should be offered to all people with schizophrenia, starting either during the acute phase (including in-patient settings) or later, but are beyond the scope of this guideline.
Guidance from an appropriate specialist mental health clinician should be sought in all instances of psychotic illness unless the practitioner is experienced at managing these conditions.
Offer oral antipsychotic medication. The choice of drug should be made jointly by the individual and healthcare professional, considering:
There is no evidence of improved efficacy between first generation antipsychotic drugs and second-generation antipsychotics, with the exception of clozapine.
At the start of treatment give a dose at the lower end of the licensed range and slowly titrate upwards within the dose range given in the BNF or SPC. Do not use loading doses of antipsychotic drugs. Carry out a trial of the medication at the optimum dosage for 4–6 weeks.
Risperidone is considered the treatment of choice if there is no preference between available antipsychotic treatments, based on clinical presentation and/ or individual preference.
See guidance below for alternative antipsychotics appropriate to be prescribed in certain circumstances or conditions. It is not a substitute for the BNF or SPC but can help guide the individual in their choice (adapted from Bazire; Psychotropic Drug Directory 2009).
|Area of concern||Antipsychotics that may be appropriate|
All have moderate risk in renal impairment
Raised prolactin is associated with sexual dysfunction in men and amenorrhoea and lactation in women
|Extrapyramidal side effects (EPSEs)||
(Risperidone, Quetiapine, Sulpiride and Haloperidol are associated with transient sedative properties)
Refer to the individual's history looking for previous evidence of successful pharmacological treatment. The same principles of individual-led choice apply in order to promote improved concordance with the prescribed regime. Take into account the clinical benefit and side effects experienced by the individual with any previous medication.
When initiating depot/long-acting injectable antipsychotic medication:
Consider offering depot antipsychotic medication to people with schizophrenia:who would prefer such treatment after an acute episode OR non-adherence to antipsychotic medication where avoiding covert non-adherence (either intentional or unintentional) to antipsychotic medication is a clinical priority within the treatment plan
Initially use a small test dose as set out in the BNF or SPC.
Pipotiazine depot injection will be discontinued from the end of March 2015. No new patients will receive pipotiazine. Patients currently receiving pipotiazine will be switched to an alternative treatment.
See 4.2.6 Psychoses and schizophrenia
Long-acting aripiprazole, olanzapine and paliperidone injections are currently approved as hospital only drugs until other service arrangements are in place.
Specific indications for these medications in people with schizophrenia are:
See section 4.2 Drugs used in psychoses and related disorders (second-generation)
Do not use combinations of two or more antipsychotics except where:
For people with schizophrenia whose illness has not responded adequately to pharmacological or psychological treatment:
Clozapine may be offered to people with schizophrenia whose illness has not responded adequately to treatment despite the sequential use of adequate doses of at least two different antipsychotic drugs. At least one of the drugs should be a non-clozapine atypical antipsychotic.
For people with schizophrenia whose illness has not responded adequately to clozapine at an optimised dose, healthcare professionals should consider the points above (including measuring therapeutic drug levels) before adding a second antipsychotic to augment treatment with clozapine. An adequate trial of such an augmentation may need to be up to 8–10 weeks.
Patients with schizophrenia should have physical health monitoring (including cardiovascular disease risk assessment) at least once a year.
Inform the individual that there is a high risk of relapse if they stop medication in the next 1–2 years. If antipsychotic medication has to be withdrawn, reduce the dose gradually and monitor regularly for signs and symptoms of relapse. After withdrawal from antipsychotic medication, continue monitoring for signs and symptoms of relapse for at least 2 years.
In cases of acute and severe adverse effects (i.e. blood dyscrasia with clozapine) where abrupt discontinuation of medication is required, specialist advice should be sought to ensure adequate support is available and to ensure an urgent review of treatment is completed.
Seek expert advice, the National Teratology Information Service offers up-to-date information on all medicines in pregnancy. Tel: 0844 892 0909 (8.30 – 17.00 Monday to Friday)
Schizophrenia is associated with an increased incidence of diabetes and some newer atypical antipsychotics have been associated with increased rates of glucose intolerance and diabetes. It is advised that a specialist psychiatrist is consulted when treating people prescribed antipsychotics with newly emergent diabetes and commencing people on antipsychotics with existing diabetes.