Schizophrenia: Recognition and Management in the ED

Treatment

Unfortunately, no level I or II studies have been found that examine the indications for treatment of the psychiatric patient in the ED.⁹ Additionally, in the ED, there is an ill-defined difference between the use of psychotropic medications as an intervention after patient assessment and plan of care, and the use of these medications to control behavior without an assessment and treatment plan.⁹ Therefore, many treatment recommendations have been made based on studies in other settings.

The first line treatment for a patient with schizophrenia is monotherapy with an antipsychotic agent other than clozapine.^19-21 (Clozapine is not used as a first line agent due to its high side effect burden and the testing necessary before starting.) This is supported by multiple randomized controlled trials and is the standard of care.^22-24 The response rates in treatment with antipsychotics in studies specifically designed to examine treatment of first-episode schizophrenia are high, ranging from 46% to 96%.²³ Therefore, the emergency medicine provider can confidently reassure patients and families that antipsychotic medications are effective in treating schizophrenia. Loading doses of antipsychotics should not be used.¹⁹

Although there are only small and inconsistent differences between different antipsychotics, other than clozapine, with respect to efficacy, there are large differences in adverse effect profiles.^25-30Therefore, the choice of antipsychotic medication is generally made based on previous response to individual antipsychotic medications and relative side effects.³¹

If extrapyramidal symptoms, including tardive dyskinesia, are of particular concern to a patient, then second generation or low potency first generation antipsychotics should be used.^25,32 If a patient complains of previous problems with sedation, then haloperidol or aripiprazole should be preferred.²⁵ Haloperidol, aripiprazole, or amisulpride should be considered for patients who are particularly concerned about weight gain, or who may be at the greatest risk of weight gain.²⁵

If there is no response to medication after 4 weeks,³² despite dose optimization, a change in antipsychotic should be considered.^33,34 Where there is partial response, the patient should be re-assessed after 8 weeks unless there are significant adverse effects.^14,19,20,34 A combination of different antipsychotic medications should not be used, except during transitional periods when patients are being switched from one antipsychotic to another, or when used for clozapine augmentation.¹⁴After an acute episode has passed, providers can consider offering depot/long-acting injectable antipsychotic medication to people with schizophrenia who would prefer such treatment; as long acting injectable antipsychotics have been shown to reduce medication non-adherence.^35,36 Long-acting depot antipsychotics should not be used for acute episodes because it may take 3 to 6 months for the medications to reach a stable state.¹⁴Once a patient achieves a remission of their symptoms, patients are recommended to stay on their antipsychotic medication for at least 2 years since their last acute exacerbation.^14,34 For maintenance therapy,the antipsychotic dose should be reduced gradually to the lowest possible effective dose, which should not be lower than half of the effective dose during the acute phase.³⁷

Clozapine should be offered to people with schizophrenia whose illness has not responded adequately to treatment with adequate doses of at least two different antipsychotic drugs.^38-41There is no indication to using dual antipsychotic agents on patients with schizophrenia prior to starting a clozapine trial.^42,43