Schizoaffective Disorder

Schizoaffective disorder is a major mood episode (depressive or manic) concurrent with schizophrenia criterion A symptoms, with psychosis lasting at least 2 weeks in the absence of mood symptoms.

• Lifetime prevalence 0.3%; depressive and bipolar types.
• Prognosis is better than schizophrenia and worse than mood disorders with psychotic features.
• Suicide risk is high (5 to 10%), especially in depressive type.

• Mood episodes (mania, depression) alongside delusions or hallucinations; psychosis persists between mood episodes.
• Negative and cognitive symptoms less severe than schizophrenia.
• Relapsing course with functional impairment.

• DSM-5: uninterrupted illness with major mood episode and psychotic symptoms; clear history of psychotic symptoms for 2 weeks or more without mood episode; mood symptoms present for the majority of illness.
• Exclude bipolar disorder or depression with psychotic features, schizophrenia, substance induced disorders, medical conditions.
• Baseline labs, TSH, toxicology, metabolic panel, lithium and valproate baseline tests as needed.
• Suicide risk assessment.

• Antipsychotic is the foundation: paliperidone 6 to 12 mg daily (only agent licensed), risperidone 2 to 6 mg, olanzapine 10 to 20 mg, aripiprazole 10 to 30 mg, clozapine for resistant disease; LAI formulations for nonadherence.
• Bipolar type: add lithium (target 0.6 to 1.0 mmol/L), valproate 750 to 2000 mg (not in women of childbearing potential), or lamotrigine 100 to 200 mg.
• Depressive type: add SSRI (sertraline 50 to 200 mg) to antipsychotic.
• Manage acute mania with lorazepam, olanzapine.
• Psychosocial rehabilitation, CBT, family intervention, and relapse prevention.
• ECT for severe or treatment resistant episodes. Monitor metabolic and cardiac risk.