Approach Considerations
Treatment for schizoaffective disorder consists of both pharmacotherapy and psychotherapy. Written informed consent must be obtained before pharmacologic therapy is started. To maximize benefits and adherence to treatment, the treatment plan must be individualized for each patient. [34] Consultation with a neurologist to rule out neurologic disease is appropriate.
Patients who are suicidal, homicidal, or gravely disabled should be admitted to an inpatient psychiatric unit. Inpatient treatment is mandatory for patients who are dangerous to themselves or others and for patients who cannot take care of themselves. If patients with schizoaffective disorder represent a danger to self or others or are gravely disabled and are unwilling to seek help on a formal voluntary basis, they may have to be committed for further evaluation and treatment.
Transfer to a medical surgical hospital should be considered if it appears necessary, as should transfer to a residential or group home. Familiarity with local mental health laws is essential.
Smoking cessation [35] and noncompliance with medications [36] are special concerns. It is important to monitor treatment adherence for medications and other therapeutic activities. [37, 38]
No specific diet is recommended for patients with schizoaffective disorder. Activity should be restricted if patients represent a danger to themselves or others or if they are gravely disabled; otherwise, patients should be encouraged to continue their normal routines and strengthen their social skills whenever possible.
Pharmacologic Therapy
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. [39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57]
In the depressive subtype, combinations of antidepressants (eg, sertraline or fluoxetine) plus an antipsychotic (eg, haloperidol, risperidone, [58] olanzapine, [59] aripiprazole, [60] or ziprasidone [61, 59] ) are used. In refractory cases, clozapine has been used as an antipsychotic agent. [62] In the manic subtype, combinations of mood stabilizers (eg, lithium, carbamazepine, divalproex) plus an antipsychotic are used.
Other antipsychotics that have been used in this setting include paliperidone (the active metabolite of risperidone), [63, 64, 65, 66] iloperidone, quetiapine, and asenapine. [67]
Quetiapine is sometimes prescribed at higher than approved doses for patients with schizophrenia or schizoaffective disorder. Honer et al did not find dosages higher than 800 mg/day to offer any advantage beyond what was achievable with the approved dosage range. [68] In a study of two nationwide cohorts of patients with schizoaffective disorder identified from Finnish and Swedish registers found that quetiapine was not associated with a decreased risk of psychosis hospitalization. [69]
The use of ziprasidone dosages higher than the standard maximum of 160 mg/day has also been proposed. Goff et al, in a study comparing 160 mg/day and 320 mg/day dosages in individuals with schizophrenia or schizoaffective disorder whose symptoms did not resolve after a minimum of 3 weeks of ziprasidone 160 mg/day, found that the higher dosage did not yield a sustained increase in serum concentrations or symptomatic improvement in comparison with the standard dosage. [70]
Selective serotonin reuptake inhibitors (SSRIs) are greatly preferred to the other classes of antidepressants. Because their adverse-effect profiles 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. This 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 stating that most SSRIs are not suitable for use by persons younger than 18 years for treatment of depressive illness. After review, the MHRA decided that the risks to pediatric patients outweighed the benefits of treatment with SSRIs, except in the case of fluoxetine, 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 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.
Noncompliance with medications is a complication of therapy. If noncompliance with medications is an issue, one may seek a court order to force the patient to take medications (eg, in lieu of rehospitalization), which may help increase medication compliance.
Psychotherapy and Psychoeducational Programs
Patients who have schizoaffective disorder can greatly benefit from psychotherapy, as well as from psychoeducational programs.
They should receive therapy that involves their families, develops their social skills, and focuses on cognitive rehabilitation. Expressed emotions must be reduced in all areas of a patient’s life, including stress-reduction techniques employed to prevent relapse [71] and possible rehospitalization. Psychotherapies should include supportive therapy and assertive community therapy in addition to individual and group forms of therapy and rehabilitation programs.
Treatment includes education about the disorder and its treatment, family assistance in compliance with medications and appointments, and maintenance of structured daily activities (eg, a schedule of daily events) for the patient.
Family involvement is needed in the treatment of this particular disorder. [72] Family education is particularly important in this disorder secondary to the various mood and psychotic states. Families need information regarding the patient’s mediations and the dynamic nature of this illness.
For further information, families can contact the National Alliance on Mental Illness (NAMI) or Self-Help Association Regarding Emotions (SHARE; 1-800-832-8032).
Long-Term Monitoring
When an inpatient who has schizoaffective disorder makes the transition to being an outpatient, stressing the importance of medication compliance is crucial.
Patients with schizoaffective disorder often lack judgment and insight into their illness. They commonly refuse to continue the medications started in the hospital after they are discharged. When patients begin to feel better as a result of their medications, they may think that they no longer need to take them; such thinking leads to the discontinuance of medication and typically results in a return to the hospital within the next several weeks or so. Noncompliance can also be due to adverse effects of the medication, such as sedation and weight gain.
If possible, once-daily or long-acting medications (eg, decanoate injections) should be selected to facilitate patient compliance. In addition, the issue of compliance should be addressed with a family member. In every case, all of the risks, benefits, and adverse effects of each medication, as well as alternatives to the medication, should be discussed with the patient and family.
