Schizoaffective Disorder Medication

  • Author: Guy E Brannon, MD; Chief Editor: David Bienenfeld, MD   more...
 
Updated: Feb 16, 2012
 

Medication Summary

Several medications are used to treat schizoaffective disorder. Agent selection depends on whether the depressive or manic subtype is present. Early treatment with medication along with good premorbid function often improves outcomes.

In the depressive subtype, combinations of antidepressants (eg, sertraline, fluoxetine) plus an antipsychotic (eg, haloperidol, risperidone, olanzapine, aripiprazole, or ziprasidone) are used. In refractory cases, clozapine has been used as an antipsychotic agent. In the manic subtype, combinations of mood stabilizers (eg, lithium, carbamazepine, divalproex) plus an antipsychotic are used.

Quetiapine is sometimes prescribed at higher than approved doses for patients with schizophrenia or schizoaffective disorder. Honer et al suggest doses greater than 800 mg/d did not show any advantage beyond the approved dose range.[63]

Of the many medications and combinations available to treat schizoaffective disorder, a few are reviewed below.

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Antipsychotics

Class Summary

These agents ameliorate psychosis and aggressive behavior.

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Haloperidol (Haldol)

 

Haloperidol is used for management of psychosis, as well as motor and vocal tics in children and adults. The mechanism of action not clearly established, but the drug has a selective effect on the central nervous system (CNS) by competitively blocking postsynaptic dopamine (D2) receptors in the mesolimbic dopaminergic system; increases in dopamine turnover are responsible for the tranquilizing effect. With subchronic therapy, depolarization blockade and D2 postsynaptic blockade are responsible for antipsychotic action.

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Risperidone (Risperdal, Risperdal Consta)

 

Risperidone is a selective monoaminergic antagonist that binds to dopamine D2 receptors with a 20 times lower affinity than it binds to serotonin type 2 (5-HT2) receptors. It also binds to alpha1-adrenergic receptors with lower affinity to H1-histaminergic and alpha2-adrenergic receptors. It improves negative symptoms of psychosis and decreases occurrence of extrapyramidal effects.

Risperidone is also available in a long-acting intramuscular (IM) formulation (Risperdal Consta).[64]

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Olanzapine (Zyprexa)

 

Olanzapine is an atypical antipsychotic with a broad pharmacologic profile across receptor systems (eg, serotonin, dopamine, cholinergic muscarinic, alpha-adrenergic, histamine). Its antipsychotic effect is from antagonism of dopamine and serotonin type 2 receptors. It is indicated for treatment of psychosis and bipolar disorder.[65]

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Clozapine (Clozaril, FazaClo)

 

Clozapine has a weak affinity for D1, D2, D3, and D5 receptors and a high affinity for the D4 receptor. It also acts as an antagonist at adrenergic, cholinergic, histaminergic, and serotonergic receptors. However, it does not induce catalepsy, nor does it inhibit apomorphine-induced stereotypy. The risk of agranulocytosis limits the use of clozapine to patients who are nonresponsive to or intolerant of classic neuroleptic agents.

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Quetiapine (Seroquel)

 

Quetiapine is a newer antipsychotic for long-term management. It may antagonize dopamine and serotonin effects. Improvements over earlier antipsychotics include fewer anticholinergic effects and less dystonia, parkinsonism, and tardive dyskinesia.

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Ziprasidone (Geodon)

 

Ziprasidone antagonizes D2, D3, 5-HT2A, 5-HT2C, 5-HT1A, 5-HT1D, and alpha1-adrenergic receptors. It has a moderate antagonistic effect for histamine H1. It moderately inhibits reuptake of serotonin and norepinephrine.[65]

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Aripiprazole (Abilify)

 

Aripiprazole improves positive and negative schizophrenic symptoms. Its mechanism of action is unknown but is hypothesized to differ from that of other antipsychotics. Aripiprazole is thought to be a partial D2 and 5-HT1A) agonist and antagonizes 5-HT2A. No QTc-interval prolongation is noted in clinical trials.[66]

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Iloperidone (Fanapt)

 

Iloperidone is an atypical antipsychotic agent that is indicated for acute treatment of schizophrenia. Its precise mechanism of action is unknown. It antagonizes D2 and 5-HT2 receptors.

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Paliperidone (Invega)

 

Paliperidone is the active metabolite of risperidone and is the first second-generation antipsychotic approved for the treatment of schizoaffective disorder.[67, 68, 69, 70]

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Asenapine (Saphis)

 

Asenapine is an atypical antipsychotic agent indicated for schizophrenia and bipolar disorder.[71]

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Antidepressants

Class Summary

Antidepressant agents decrease aggression and treat the underlying illness.

Selective serotonin reuptake inhibitors (SSRIs) are greatly preferred over the other classes of antidepressants. Because the adverse-effect profiles of SSRIs are less prominent than the profiles of other drugs, improved compliance is promoted. SSRIs do not have the cardiac dysrhythmia risk associated with tricyclic antidepressants. Dysrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when one treats a child or adolescent with a mood disorder.

Physicians are advised to be aware of the following information and to use appropriate caution when they consider treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of depressive illness. After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except in the case of fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the US Food and Drug Administration (FDA) issued a public health advisory regarding reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

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Fluoxetine (Prozac)

 

Fluoxetine is an SSRI used to treat impulse-control problems or underlying illness. It selectively inhibits presynaptic serotonin reuptake with minimal or no effect in reuptake of norepinephrine or dopamine.

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Sertraline (Zoloft)

 

Sertraline is an SSRI used to treat impulse-control problems or underlying illness. It selectively inhibits presynaptic serotonin reuptake with minimal or no effect in the reuptake of norepinephrine or dopamine.

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Paroxetine (Paxil)

 

Paroxetine is a potent selective inhibitor of neuronal serotonin reuptake. It also has a weak effect on norepinephrine and dopamine neuronal reuptake.

For maintenance dosing, make dosage adjustments to maintain the patient on the lowest effective dosage, and reassess the patient periodically to determine the need for continued treatment.

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Fluvoxamine (Luvox)

 

Fluvoxamine enhances serotonin activity by selective reuptake inhibition at the neuronal membrane. It does not significantly bind to alpha-adrenergic, histamine, or cholinergic receptors and thus has fewer adverse effects than tricyclic antidepressants.

It has been shown to reduce repetitive thoughts, maladaptive behaviors, and aggression and to increase social relatedness and language use.

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Citalopram (Celexa)

 

Citalopram enhances serotonin activity by selective reuptake inhibition at the neuronal membrane. No head-to-head comparisons of SSRIs exist, although, based on metabolism and adverse effects, citalopram is considered the SSRI of choice for patients with head injury.

SSRIs are the antidepressants of choice because of their minimal anticholinergic effects.

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Escitalopram (Lexapro)

 

Escitalopram is a selective serotonin reuptake inhibitor (SSRI) and S-enantiomer of citalopram. It is used for the treatment of depression. The mechanism of action is thought to be potentiation of serotonergic activity in the CNS, resulting from the inhibition of CNS neuronal reuptake of serotonin. The onset of depression relief may be obtained after 1-2 weeks, which is sooner than other antidepressants.

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Mood Stabilizers

Class Summary

Mood stabilizers stabilize the mood imbalance associated with bipolar disorder.

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Valproic acid (Depakote, Depakene, Depacon, Stavzor)

 

Valproic acid may increase brain gamma-aminobutyric acid (GABA) levels by inhibiting aminobutyrate aminotransferase. GABA inhibits presynaptic and postsynaptic discharges. In addition to its use as mood stabilizer, valproic acid is also used for migraine headaches, epilepsy, and mania.

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Oxcarbazepine (Trileptal)

 

Oxcarbazepine's pharmacologic activity is primarily from its 10-monohydroxy metabolite (MHD). It may block voltage-sensitive sodium channels, inhibit repetitive neuronal firing, and impair synaptic impulse propagation. Its anticonvulsant effect may also occur by affecting potassium conductance and high-voltage activated calcium channels.

Drug pharmacokinetics are similar in children older than 8 years and adults. Children younger than 8 years have a 30-40% increased clearance compared with older children and adults. Use of oxcarbazepine in children younger than 2 years has not been studied in controlled trials.

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Lithium (Lithobid)

 

Lithium is indicated to treat bipolar disorder. The specific mechanism of action unknown, but the drug alters sodium transport in nerve and muscle cells and influences reuptake of serotonin, norepinephrine, or both at cell membranes.

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Carbamazepine (Tegretol, Carbatrol, Epitol, Equetro)

 

Carbamazepine is indicated to treat epilepsy and trigeminal neuralgia. Research and clinical experience indicate that it is effective in treating manic subtype schizoaffective disorder.

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Contributor Information and Disclosures
Author

Guy E Brannon, MD  Associate Clinical Professor of Psychiatry, Louisiana State University Health Sciences Center; Director, Adult Psychiatry Unit, Chemical Dependency Unit, Clinical Research, Brentwood Behavior Health Company

Guy E Brannon, MD is a member of the following medical societies: American Medical Association, American Medical Writers Association, American Psychiatric Association, American Society of Addiction Medicine, Association of Clinical Research Professionals, Louisiana State Medical Society, and Southern Medical Association

Disclosure: AstraZeneca Grant/research funds Other; Janssen Grant/research funds Other; Pfizer Honoraria Speaking and teaching; Sunovion Honoraria Speaking and teaching; Eli Lilly Grant/research funds Other; Forrest Grant/research funds Other

Chief Editor

David Bienenfeld, MD  Professor of Psychiatry, Vice-Chair and Director of Residency Training, Department of Psychiatry, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Additional Contributors

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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