Text Size :
A A A

Treatment Guidelines for Schizophrenia

The following treatment guidelines are meant as a reference tool only, and are not intended as treatment advice or to replace the clinical decision-making process of psychiatrists or other health professionals who administer these treatments. In clinical practice there are often good reasons why treatment approaches differ from what is described here.

 

Step 1:  Offer psychoeducation and case-management, and consider using other psychosocial treatments at any point if needed.

Step 2:  Start an Atypical Antipsychotic:

    • Start at the lowest possible dose (unless the person has required higher doses in the past).
    • Increase the dose every 2-4 weeks depending on how the person responds to the medication.
    • If after 6-9 weeks of having started the treatment there is not a significant improvement in the person's condition, even after a few weeks at a high dose, then go to Step 3.
    • If within 6-9 weeks of starting the medication there is significant improvement in the person's condition, go to Step 7. 

Step 3:  Taper and discontinue the medication chosen in Step 2, and at the same time start a different Atypical Antipsychotic or a Typical Antipsychotic:

    • Start at a medium dose of the Atypical Antipsychotic or a low dose of the Typical Antipsychotic.
    • Increase the dose every 2-4 weeks depending on how the person responds to the medication.
    • If after 6-9 weeks of having started the treatment there is not a significant improvement in the person's condition, even after a few weeks at a high dose of the Atypical Antipsychotic or at a moderate dose of the Typical Antipsychotic, then go to Step 4.
    • If within 6-9 weeks of starting the medication there is significant improvement in the person's condition, go to Step 7. 

Step 4:  Taper and discontinue the medication used in Step 3, and at the same time start Clozapine:

    • If the Clozapine is not well tolerated due to side-effects, discontinue it and go to Step 6.
    • If after 4-6 months of having started Clozapine there is not a significant improvement in the person's condition, even after a couple of months at a high dose, then go to Step 5.
    • If within 4-6 months of having started Clozapine there is significant improvement in the person's condition, go to Step 7.

Step 5:  Take the opportunity to re-evaluate the person's diagnosis, and explore whether there are any current substance use problems, medication adherence difficulties, or significant life stressors. If addressing these issues does not bring any clinical gains, add one of the following options to the Clozapine (a or b):

  1. Try a course of ECT.
    • If after a full course of ECT the person's condition does not improve, go to Step 5b or Step 6.
    • If there is a significant improvement in the person's condition, go to Step 7.

  2. Add another antipsychotic to the Clozapine, either an Atypical or a Typical, but preferably one that was not tried in a previous step.
    • Start at a low dose.
    • Increase the dose every 2-4 weeks depending on how the person responds to this medication.
    • If after 4-6 weeks at a high dose of the Atypical Antipsychotic or at a moderate dose of the Typical Antipsychotic there is not a significant improvement in the person's condition, stop this medication and either repeat Step 5b, try Step 5a if not already done, or go to Step 6.
    • If there is a significant improvement in the person's condition, go to Step 7.

Step 6:  Try the following options, with or without discontinuing the Clozapine (keep trying these different options until hopefully one is effective, and then go to Step 7):

  1. Start an antipsychotic that was not yet tried, using the dosing schedule described in Step 3.
  2. Combine two antipsychotic medications (other than Clozapine), using the dosing schedule described in Step 3.
  3. Add a Mood Stabilizer (in combination with an antipsychotic), and allow 4-6 weeks at the maximum tolerated dose before deciding that it is not effective.
  4. Try a course of ECT, if not already tried

Step 7:  Continue on an on-going basis the treatment(s) that worked.

    • Given that there is a 90% risk of relapsing into the active phase of Schizophrenia after two years of stopping medications [ref], it is recommended to continue the treatments on an ongoing basis. 
    • If, despite these recommendations, a person wishes to stop their medications, this should be done very gradually over a period of 6 months to 1 year, with close monitoring and regular follow-ups even after the medications have been stopped.
    • If ECT was what helped, continue whatever medications had been partially effective before the ECT treatment was tried.
    • For individuals who have significant violent or suicidal tendencies, Clozapine should be considered as a maintenance treatment given that it can help to moderate these tendencies.

Note: In patients with difficulty adhering to their medication regimen, using long-acting Risperidone, Haloperidol or Fluphenazine should be considered at any point in the above steps.

 

For references in support of the above guidelines, see [ref, ref].

 

Medications

Treating Depression that occurs in Schizophrenia