How to handle a schizoaffective disorder patient?

Question

Hi doctor,

My brother is 37 years old and has been suffering from schizophrenia or schizoaffective disorder with confusion for the past three and a half years. His symptoms include auditory hallucinations, delusions, aggression, talking to himself, grandiosity, and racing thoughts. Initially, he was treated with Risperidone 3 mg for a year and a half, during which he gained some insight into his condition. However, he experienced some issues with Risperidone. After a year, his doctor switched his medication to Quetiapine 400 mg. Within two months, his symptoms disappeared, including auditory hallucinations and delusions. He seemed to improve, so the doctor gradually reduced the Quetiapine dose to 300 mg and then to 200 mg. After being stable for three to four months, we stopped the medication, which led to a relapse of symptoms.

The doctor then increased the Quetiapine dose back to 300 mg, and the symptoms resolved within a month. However, despite regular medication adherence, in the past month, new symptoms have emerged, including racing thoughts, aggression, intermittent weeping and laughing, and suicidal thoughts. The doctor has since increased the Quetiapine dosage to 400 mg and then to 600 mg, in addition to Clonazepam 75 mg. Despite these adjustments, his symptoms have not improved.

We are seeking advice on alternative medications and how best to manage his condition. Additionally, he has a history of high blood pressure, fatty liver, and gallbladder stones, and is currently taking Amlodipine with Atenolol and Ursodeoxycholic acid.

Please suggest.

Answer 1

Hi,

Welcome to icliniq.com.

I read your query with keen interest and understand your concern about your brother's poor response to the current antipsychotic medications.

First, I believe Aripiprazole would be the best choice, especially given his hypertension and gallbladder issues. Most newer antipsychotics tend to increase blood pressure over time, but Aripiprazole does not have this effect. Both Quetiapine and Risperidone are known to potentially increase blood pressure and weight, so they should be avoided if possible. We also need to consider the drug's tolerability. Given his poor response to Quetiapine and difficulties with Risperidone, Aripiprazole seems to be a suitable option. If his psychiatrist has valid reasons against using Aripiprazole, other options like Lurasidone or Ziprasidone could be considered.

The typical dose of Aripiprazole ranges from 10 to 30 mg. It would be reasonable to start with 10 mg and monitor his response for two weeks before increasing the dose if needed. Please consult with your specialist doctor, discuss this option, and proceed with their guidance.

Regarding the diagnosis, it seems appropriate to classify his condition as schizoaffective disorder, given the presence of both schizophrenia and affective disorder symptoms. For further management, it is crucial to avoid additional experimentation with medications. He needs consistent medication adherence, and any discontinuation of medication should only occur in emergency situations.

Supporting the patient during this challenging time is also essential. Maintaining a non-hostile environment is important, as research indicates that critical feedback can increase the risk of relapse. Therefore, it is advisable to avoid critical comments as much as possible.

I hope this information is helpful. Please feel free to reach out if you have more questions. I would be glad to assist you further.

Thanks and regards.

Answer 2

Hi,

Welcome back to icliniq.com.

I am sorry to hear that managing him has been difficult despite the use of 600 mg of Quetiapine. Ideally, hospitalization would be necessary, as it can be challenging to manage acute schizophrenia symptoms, including aggression, outside a hospital setting. If hospitalization is not possible for some reason, I recommend the following:

Avoid arguing with the patient.
Try to redirect the patient’s attention to neutral topics if they become aggressive.
Engage the patient in activities whenever possible.
Consider administering an injection of Haloperidol 10 mg combined with Promethazine 50 mg, under the supervision or guidance of a local doctor or psychiatrist. This combination is often used during hospitalization and has been found to be effective.

For treating auditory hallucinations, electroconvulsive therapy (ECT) is the most effective, followed by antipsychotic medications. Repetitive transcranial magnetic stimulation (rTMS) and other brain stimulation techniques have limited effectiveness and are usually considered only if other treatments are inadequate or ineffective.

Regarding a cure, I must clarify that there is no complete cure for schizophrenia at this time; treatment aims to manage the symptoms. While naturopathy and yoga may offer some benefits, they should not be considered primary treatments. Repeated testing has limited value beyond research and ruling out other conditions.

When transitioning to Aripiprazole, the dose should be increased gradually while decreasing the Quetiapine dose, under the guidance of the treating doctor. A common approach is to start with 10 mg of Aripiprazole and monitor the response for two weeks. If there is an inadequate response, increase the dose by 10 mg after two weeks. During this period, keep the Quetiapine dose stable for two weeks before starting to reduce it by 100 mg every two weeks. However, individual treatment plans may vary, and the treating doctor will provide the best guidance.

I hope this information is helpful. Please feel free to reach out if you have further questions.

Thanks and regards.