Quick Reference for Schizophrenia
Feature | Good Outcome | Poor Outcome |
---|---|---|
Age | Older | Younger |
Gender | Female | Male |
Social class | High | Low |
Marital history | Married | Never married |
Family history of schizophrenia | Negative | Positive |
Perinatal complications | Absent | Present |
Transcultural factors | Developing nations | Industrialized nations |
Premorbid functioning | Good | Poor |
Onset | Acute | Insidious |
Duration | Short | Chronic |
Sensorium | Clouded | Clear |
Symptoms/subtypes | Paranoid subtype | Deficit syndrome |
Affective symptoms | Present | Absent |
Neurological functioning | Normal | Soft signs present |
Neurocognition | Normal | Abnormal |
Structural brain abnormalities | None | Present |
When the illness is new, to rule out alternative diagnoses and to stabilize the dose of antipsychotic medication |
For special medical procedures such as electroconvulsive therapy |
When aggressive or assaultive behavior presents a danger to the patient or others |
When the patient becomes suicidal |
When the patient is unable to properly care for himself or herself (e.g., refuses to eat or take fluids) |
When medication side effects become disabling or potentially life threatening (e.g., severe pseudoparkinsonism, severe tardive dyskinesia, neuroleptic malignant syndrome) |
Efficacy |
Schizophrenia (FDA approved for all) |
Treatment-resistant schizophrenia (clozapine) |
Mania (FDA approved for olanzapine) |
Depression/anxiety/agitation (efficacy established but not FDA approved for these purposes) |
Side effects |
Weight gain |
Sedation |
Akathisia |
Orthostatic hypotension |
Dizziness |
↑ Triglycerides |
EPS, NMS (rare) |
Agranulocytosis (clozapine) (rare) |
Seizures (clozapine) |
Safety in overdose |
Seizures with clozapine in overdose. Respiratory depression in combination with other CNS depressants. QT interval changes. Lavage and vital sign support |
Dosage and administration |
Clozapine: 12.5–25 mg; then increase dosage 25–50 mg per week, as needed and tolerated, to 300–600 mg/day |
Risperidone: 0.5–1 mg b.i.d. to 3 mg b.i.d. by end of first week, as tolerated |
Olanzapine: 2.5–5 mg h.s.; increase by 5 mg every week to 20 mg h.s. |
Quetiapine: 25 mg b.i.d.; increase total daily dose by 50 mg, as needed and tolerated, to 300–600 mg/day |
Ziprasidone: 20 mg/day or b.i.d.; increase by 20–40 mg per week, to a maximum dosage of 80 mg b.i.d. |
Aripiprazole: 15 mg/day; increase up to 30 mg/day after 1 week |
Full benefits in 4 weeks to 6 months |
Discontinuation |
Mild cholinergic rebound, faster relapse |
Taper as slowly as titrated up |
Drug interactions |
Fluvoxamine (1A2 inhibitors): ↑ atypical antipsychotic levels |
EtOH: ↑ sedation and orthostasis |
Antihypertensives: may ↑ orthostasis |
Carbamazepine: ↓ serum levels of olanzapine; contraindicated with clozapine |
CNS depressants: ↑ sedation |
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Table 4. Typical Antipsychotics: Metabolism and Enzyme Inhibition
Drug | Major Metabolism Site(s) | Enzyme(s) Inhibited |
---|---|---|
Aripiprazole | 2D6, 3A4 | None known |
Clozapine | 1A2, 3A4, 2D6, 2C19, UGT1A4, UGT1A3 | 2D6a |
Olanzapine | 1A2, 2D6, UGT1A4, ?other UGTs, ?FMO3 | None known |
Quetiapine | 3A4, sulfation | None known |
Risperidone | 2D6, 3A4 | 2D6b |
Ziprasidone | Aldehyde oxidase, 3A4, 1A2 | None known |
Women experience more mood symptoms |
Men experience more deficit symptoms |
Women present as more socially appropriate |
Delusional themes differ between the two sexes |
Men engage in more substance abuse |
Women have more comorbid problems (allergies, endocrine disturbances, eating disorders, posttraumatic stress disorders, psychophysiological disorders) |
Symptoms | Alzheimer’s Disease | Schizophrenia |
---|---|---|
Delusions | ||
Someone stealing | +++ | ++ |
Thought control | +/− | ++/+++ |
Hallucinations | ||
Auditory | +/++ | ++/+++ |
Visual | ++/+++ | + |
Cognitive impairment | ||
Short-term memory loss | +++ | + |
Word-finding difficulties | ++/+++ | −/+ |
Disorientation | ++ | −/+ |
Mini-Mental State Examination | Gradual decline | More or lesss constant |
Family history | Alzheimer’s disease | Major mental disorder |
Course | Progressive decline | Variable |
Typical social situation | Married, widowed, divorced, not socially isolated | Single, socially isolated |
Extrapyramidal Side Effects/Tardive Dyskinesia | Prolactin Elevation | Weight Gain | Glucose Abnormalities | Lipid Abnormalities | QTc Prolongation | Sedation | Hypotension | Anticholinergic Side Effects | |
---|---|---|---|---|---|---|---|---|---|
Thioridazine | + | ++ | + | +? | +? | +++ | ++ | ++ | ++ |
Perphenazine | ++ | ++ | + | +? | +? | 0 | + | + | 0 |
Haloperidol | +++ | +++ | 0 | 0 | 0 | 0 | ++ | 0 | 0 |
Clozapinea | 0b | 0 | +++ | +++ | +++ | 0 | +++ | +++ | +++ |
Risperidone | + | +++ | ++ | ++ | ++ | + | + | + | 0 |
Olanzapine | 0b | 0 | +++ | +++ | +++ | 0 | + | + | ++ |
Quetiapinec | 0b | 0 | ++ | ++ | ++ | 0 | ++ | ++ | 0 |
Ziprasidone | 0b | + | 0 | 0 | 0 | ++ | 0 | 0 | 0 |
Aripriprazoled | 0b | 0 | 0 | 0 | 0 | 0 | + | 0 | 0 |