Schizophrenia

Schizophrenia - Chronic
Rahul Soman, M. Pharm

 

 

Definition  

A psychotic disorder usually characterized by withdrawal from reality, illogical patterns of thinking, delusions, and hallucinations, and accompanied in varying degrees by other emotional, behavioral, or intellectual disturbances, mostly in cycles of exacerbation and remission

 

Ongoing Assessment  

 

Reassessment  

 

Annually and as Clinically Indicated  

 

Monitoring of physical status and detecting concomitant physical conditions in patients with schizophrenia  

* Complete blood count

* Electrolytes measurement, serum

* Hepatic function panel

* Thyroid panel

* Renal function monitoring

 

Substance abuse  

* Toxicology screening test

 

Hyperglycemia  

* Plasma random glucose measurement

 

Medical History  

* Family history of Schizophrenia

* Substance Abuse

* Past medical history of Complication related to pregnancy

 

Findings  

* Abnormal movement

* Agitation

* Anhedonia

* Anxiety

* Delusions

* Depression - Chronic

* Disturbance in speech

* Flat affect

* Hallucinations

* Impaired cognition

* Impaired social interaction

* Lack of insight

* Loss of motivation

* Neglected appearance

* Poverty of speech

* Suicidal thoughts

* Wandering

 

Tests  

 

Schizophrenia and psychosis  

* White blood cell count: Inhibition of leukopoiesis, can occur with the use of clozapine or first-generation antipsychotic medications .

 

Suspected and known psychotic disorder  

* MRI of head: The MRI has demonstrated a variety of generalized and regional abnormalities among patients with schizophrenia .

 

Suspected anemia  

* Hematocrit determination: Very mild anemias are associated with few or no clinical signs or symptoms; therefore, a mild anemia usually is first detected from a screening measurement of Hgb or HCT.

 

Suspected hyperglycemia  

* Plasma random glucose measurement: A hyperglycemic hyperosmolar syndrome is characterized by a serum glucose level greater than 600 mg/dL.

 

Suspected hypernatremia  

* Sodium measurement, serum: A serum sodium level greater than 145 mEq/L defines hypernatremia in adults .

 

Suspected hypoglycemia  

* Plasma random glucose measurement

 

Suspected hyponatremia  

* Sodium measurement, serum: Hyponatremia is a sodium serum concentration less than 136 mEq/L and severe hyponatremia is a serum sodium concentration of less than 120 mEq/L .

 

Suspected hypercalcemia  

* Serum calcium measurement: Hypercalcemia is defined as a serum calcium level greater than 10.5 mg/dL . A level higher than 13.5 mg/dL should be treated aggressively .

 

Assessment of liver function and as a baseline prior to starting pharmacotherapy  

* Hepatic function panel

 

Suspected hyperthyroidism  

* Thyroid stimulating hormone measurement: Overt hyperthyroidism is defined as a serum TSH less than 0.1 milliunits/L (mU/L) in the presence of an elevated serum free thyroxine (FT4), thyroxine (T4), or serum free triiodothyronine (FT3). Subclinical hyperthyroidism is defined as a TSH below the statistically defined lower limit of the reference range in the presence of a normal FT4 and FT3.

 

Suspected hyperthyroidism in patients with atrial fibrillation  

* Thyroid stimulating hormone measurement: A TSH level ?0.1 milliunits/L (mU/L) is associated with an increased risk of atrial fibrillation .

 

Differential Diagnosis  

* Psychotic disorder - Acute

* Personality disorder - Chronic

* Delusional disorder

* Schizoaffective disorder

* Mood disorder

* ETHANOL

* Substance abuse

* Delirium - Acute

* Neurosis

* Obsessive-compulsive disorder

* Seizure

* Huntington's disease - Chronic

* Subdural hematoma - Acute

* Normal pressure hydrocephalus

* Intracranial tumor

* Autistic thinking

* Cerebrovascular accident

* Infectious disease

* Sepsis syndrome

* Meningitis

* Encephalitis

* Metabolic disease

* Disorder of lipid storage and metabolism

* Heart failure

* Hypertensive encephalopathy

* Wernicke-Korsakoff syndrome - Acute

* Alzheimer's disease

* Neurosyphilis

* Pituitary dependent hypercortisolism

* Hepatic encephalopathy

* Renal failure

* Hypoglycemia - Acute

* Abnormal thyroid hormone

* Addison's disease

* Hyperparathyroidism

* Hyponatremia - Acute

* Hypernatremia - Acute

* Encephalopathy associated with AIDS

* Pneumonia

* Urinary tract infectious disease - Acute

* CARBON MONOXIDE

* LEAD

* MERCURY, ELEMENTAL

* Congenital malformation

* Developmental disorder

* Child abuse

* Systemic lupus erythematosus - Chronic

 

Treatment  

 

Drug Therapy  

 

 

Therapy for acute schizophrenia  

 

RISPERIDONE (Related toxicological information in RISPERIDONE)  

Adults: Initial dose 2 mg orally daily in a single dose or divided in 2 doses; increase in increments of 1 to mg a day, as tolerated, to a recommended dose of 4 to 8 mg/day

Pediatrics (13 to 17 years): Initial dose 0.5 mg orally once a day; increase in increments of 0.5 mg to 1 mg per day at intervals not less than 24 hours, as tolerated, to a target dose of 3 mg/day, effective dose range 1 to 6 mg/day

 

OLANZAPINE (Related toxicological information in OLANZAPINE)  

Adults: Initial dose 5 mg to 10 mg orally once daily, increasing to a target dose of 10 mg/day within several days; may increase or decrease the dosage by 5 mg/day at intervals of at least 1 week; usual dose range 10 mg to 30 mg orally daily

Adults (acute agitation): Initial dose 5 mg to 10 mg IM; maximal dosing three 10 mg doses given 2 to 4 hours apart

 

QUETIAPINE FUMARATE  

Adults: Initial dose 25 mg orally twice daily; may increase dose by 25 mg to 50 mg 2-3 times a day on the 2nd and 3rd day, as tolerated, to a target dose range of 300 mg to 400 mg daily by the fourth day, given in 2-3 divided doses; usual dose range is 300 mg to 800 mg orally daily

Adults: Extended-release tablets: Initial dose 300 mg orally once daily (preferably in the evening); may increase dose at intervals as short as 1 day and in increments up to 300 mg daily, to a dose range of 400 mg to 800 mg daily, as needed or tolerated; should be taken without food or with a light meal

 

ZIPRASIDONE HYDROCHLORIDE  

Adults: Initial dose 20 mg orally twice daily with food; may increase dose every 2 days up to 80 mg twice daily; usual dose range 120 mg to 200 mg orally daily

Adults (acute agitation): 10 mg IM every 2 hours OR 20 mg IM every 4 hours; maximum dose 40 mg/day

 

ARIPIPRAZOLE (Related toxicological information in ARIPIPRAZOLE)  

Adults: Initial dose 10 mg to 15 mg orally once daily (maximum 30 mg/day); usual dose range 10 mg to 30 mg daily

Pediatrics (13 to 17 years): Initial dose 2 mg orally once daily, increase to 5 mg after 2 days and to target dose of 10 mg orally once daily after 2 additional days; subsequent dose increases by 5 mg increments (maximum dose 30 mg/day)

 

HALOPERIDOL (Related toxicological information in BUTYROPHENONES)  

Adults: Initial dose 0.5 mg to 5 mg orally 2-3 times daily; maximum dose 100 mg daily; usual dose range 5 mg to 20 mg orally daily

Adults (acute agitation): 2 mg to 5 mg IM; depending on the response of the patient, subsequent doses may be given as often as every hour, although 4-8 hour intervals may be satisfactory; maximum dose 100 mg/day

 

LOXAPINE HYDROCHLORIDE  

Adults: Initial dose 10 mg orally twice daily; may increase dosage rapidly during the first 7-10 days to reach the usual effective range of 60 mg to 100 mg daily in 2-4 divided doses

Adults (acute agitation): Initial dose 12.5 mg to 50 mg IM every 4-6 hours; maximum daily dose 250 mg

 

MOLINDONE HYDROCHLORIDE  

Adults: Initial dose 50 mg to 75 mg orally daily in 3-4 doses, increased to 100 mg/day in 3-4 days; usual dose range 30 mg to 100 mg orally daily

 

THIOTHIXENE  

Adults: Initial dose 2 mg orally 3 times daily OR 5 mg orally 2 times daily; maximum dose 60 mg/day; usual dose range 15 mg to 50 mg/day

Adults: Initial dose 4 mg IM 2-4 times daily; maximum dose 30 mg/day

 

FLUPHENAZINE HYDROCHLORIDE  

Adults: Initial dose 2.5 mg to 10 mg orally in divided doses every 6-8 hours; usual dose range 5 mg to 20 mg/day

Adults: Initial dose 1.25 mg IM; adjust dose and repeat as necessary and tolerated to a total dosage of 2.5 mg to 10 mg/day in divided doses every 6-8 hours

 

THIORIDAZINE HYDROCHLORIDE  

Adult: Initial dose 50 mg to 100 mg orally 3 times daily; increase gradually to maximum dose 800 mg/day in 2-4 divided doses; usual dose range 300 mg to 800 mg/day

 

CHLORPROMAZINE  

Adults: Initial dose 25 mg to 50 mg orally 3 times daily; increase gradually until effective dose is reached; usual dose range 300 mg to 1000 mg/day

Adults (acute agitation): Initial dose 25 mg IM; if necessary, give additional 25 mg to 50 mg IM in 1 hour; increase subsequent IM doses gradually over several days as needed up to 400 mg IM every 4-6 hours until the patient is controlled

 

CLOZAPINE (Related toxicological information in CLOZAPINE)  

Adults: 12.5 mg to 25 mg orally once or twice daily; increase gradually by a maximum of 25 mg to 50 mg/day as tolerated; maximum dose 900 mg/day; usual dose range 150 mg to 600 mg/day; close hematological monitoring is required

 

LORAZEPAM  

Adults (acute agitation): 2 mg to 4 mg orally OR 2 mg IM OR 1 mg to 2 mg IV; repeat as needed for 48-72 hours

 

Procedural Therapy  

 

Psychotic disorder  

* Electroconvulsive therapy: ECT may be helpful for patients with profound depression and psychosis .

 

Schizophrenia  

* Substance abuse counseling: Untreated substance or alcohol abuse can hinder treatment efforts for patients with schizophrenia.

 

Schizophrenia  

* Psychotherapy: Intensive individual psychotherapy may not be effective for patients with schizophrenia; however, the use of supportive psychotherapy may help enhance patient compliance.

* Clozapine monitoring: Clozapine therapy should be stopped if signs or symptoms of infection, or impending or actual agranulocytosis are present .

 

Non-Procedural Therapy  

 

Schizophrenia  

* Patient Education