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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Schizoaffective disorder was first described in the 1930s. This psychiatric condition has features of both schizophrenia and mood disorders - eg, depression. Questions have been raised about whether it truly exists as a disease entity, although the term is still in common use by psychiatrists.[1, 2]
Schizoaffective disorder is less common than schizophrenia - there are no figures on the incidence and prevalence in the UK.
A population survey of psychotic disorders in Finland suggested a lifetime prevalence of 0.32%.
The condition commonly presents in early adulthood and women are more often affected.
- Controversy exists surrounding the diagnosis of schizoaffective disorder. The condition may represent a type of schizophrenia in which mood symptoms are unusually prominent, or it could represent a co-existence of schizophrenia with a mood disorder (bipolar disorder or major depression).
- In order to make the diagnosis, delusions or hallucinations need to be present for at least two weeks when the mood symptoms are not present.
- Symptoms of mood disturbance are present for a significant length of the illness.
- The disturbance is not due to other causes - eg, organic illness, substance misuse, medication (see 'Differential diagnosis', below).
The schizoaffective illness can be described as:
- Bipolar type - when a manic or a mixed episode occurs.
- Depressive type - the illness has mainly depressive episodes.
This can be divided into major depressive episode, manic episode, mixed episode and schizophrenia.
Major depressive episodeFive of the following symptoms should be present for at least two weeks. One symptom must be either depressed mood or loss of interest or pleasure:
- Depressed mood.
- Decreased pleasure in activities.
- Weight loss or weight gain or appetite change.
- Insomnia or hypersomnia.
- Psychomotor agitation or retardation.
- Feelings of guilt or worthlessness.
- Decreased concentration.
- Recurrent thoughts of death or suicidal notions.
Manic episodePersistently elevated or irritable mood for at least one week. Three of the following need to be present (or four if the patient has an irritable mood):
- Inflated self-esteem or grandiosity.
- Reduced need for sleep.
- Pressure of speech.
- Flight of ideas and racing thoughts.
- Easily distracted.
- Increase in goal-directed activity with psychomotor agitation.
- Excessive involvement in high-risk activities - eg, shopping sprees.
Mixed episodeFeatures of both manic episode and major depressive episode are present - but only for one week.
Schizophrenia symptomsTwo or more of the following are present during one month of the illness:
- Delusions - if bizarre, no other symptoms are required to make the diagnosis.
- Hallucinations - if in the form of a running commentary or two voices, no other symptoms are necessary to make the diagnosis.
- Speech abnormalities - eg, incoherent speech and/or speech derailment.
- Behavioural abnormalities - eg, disorganised or catatonia.
- Negative symptoms - eg, apathy or lack of emotions.
It is important to ascertain that the disorder is not caused by any underlying process. Main groups of differentials include:
- Substance misuse - eg, cannabis.
- Organic illness - eg, hypothyroidism, delirium, HIV.
- Medication side-effects.
- For a depressive episode, it is necessary to ensure that it cannot be explained by recent life events - eg, recent bereavement or loss of employment.
- Other psychiatric illness - eg, dementia, delusional disorder.
This will mainly be to rule out underlying causes and may include:
- Baseline bloods: FBC, renal and liver function, TFTs, HIV test.
- Urine or plasma toxicology.
- CXR to exclude pneumonia in the elderly.
- Other imaging if clinically indicated - eg, patients with abnormal neurology may require CT or MRI scanning.
Patients affected by schizoaffective disorder can also have a number of other problems. These can include:
- Learning difficulties.
- Abnormal personality - eg, antisocial or dependent.
- Poor social integration and function.
- Difficulties with relationships.
- Substance misuse - eg, alcohol.
- Suicidal behaviour.
- Homicidal thoughts.
Urgent hospital admission should be arranged for patients who are thought to be a threat to themselves or others, or who are too disabled to care for themselves. If the patient lacks capacity, compulsory admission under the Mental Health Act may be required.
Community services may be vital in keeping patients out of hospital or in managing the step-down into the community after hospital discharge. Specialist services which may be required include community psychiatric nursing and occupational therapy as well as more pragmatic support such as transport to and from hospital appointments, pharmacy delivery services and help in managing domestic and financial affairs.
There are few large trials that have specifically studied the drug treatment of schizoaffective disorder and there are no consensus guidelines. Treatment is based largely on the treatment of schizophrenia. Antipsychotics are the mainstay of treatment, sometimes combined with psychological therapies.
Treatments can be divided as:
- Treatment of an acute exacerbation of schizoaffective disorder - antipsychotics are useful and it may be that atypical antipsychotics have some qualities superior to typical antipsychotics - eg, risperidone or olanzapine. Paliperidone, a metabolite of risperidone, is showing promising results.
- Long-term treatment of schizoaffective disorder - this involves the use of antipsychotics with psychological treatments. Antipsychotics improve patients with schizoaffective disorder, being more efficacious in those with bipolar type. Atypical antipsychotics may be more effective in schizoaffective disorders but more research is required here. Clozapine is sometimes used in resistant cases.
- Treatment of ongoing depressive symptoms in schizoaffective disorder - in this situation a trial of antidepressants is warranted and these may need to continue for longer periods of time. Sertraline or fluoxetine are often used. Occasionally, electroconvulsive therapy may be required.
- Mood stabilisers such as lithium may be useful in the bipolar type. Carbamazepine is not recommended due to lack of evidence.Valproic acid has been used with some good results.
Psychological treatments involve cognitive behavioural therapy, family interventions, counselling, art therapy and supportive psychotherapy.
The bipolar type of schizoaffective disorder has a better prognosis than the depressive type, as the latter usually results in long-term mood disturbance.
Further reading and references
Kantrowitz JT, Citrome L; Schizoaffective disorder: a review of current research themes and pharmacological CNS Drugs. 2011 Apr 125(4):317-31. doi: 10.2165/11587630-000000000-00000.
Jager M, Haack S, Becker T, et al; Schizoaffective disorder-an ongoing challenge for psychiatric nosology. Eur Psychiatry. 2011 Apr26(3):159-65. Epub 2010 Jun 19.
Hamshere ML, Green EK, Jones IR, et al; Genetic utility of broadly defined bipolar schizoaffective disorder as a diagnostic concept. Br J Psychiatry. 2009 Jul195(1):23-9.
Arroll MA, Wilder L, Neil J; Nutritional interventions for the adjunctive treatment of schizophrenia: a brief review. Nutr J. 2014 Sep 1613:91. doi: 10.1186/1475-2891-13-91.
Nunes SO, Itano EN, Amarante MK, et al; RNA from Borna disease virus in patients with schizophrenia, schizoaffective patients, and in their biological relatives. J Clin Lab Anal. 200822(4):314-20. doi: 10.1002/jcla.20261.
Brown AS, Begg MD, Gravenstein S, et al; Serologic evidence of prenatal influenza in the etiology of schizophrenia. Arch Gen Psychiatry. 2004 Aug61(8):774-80.
Abrams DJ, Rojas DC, Arciniegas DB; Is schizoaffective disorder a distinct categorical diagnosis? A critical review of the literature. Neuropsychiatr Dis Treat. 2008 Dec4(6):1089-109.
Perala J, Suvisaari J, Saarni SI, et al; Lifetime prevalence of psychotic and bipolar I disorders in a general population. Arch Gen Psychiatry. 2007 Jan64(1):19-28.
Cascade E, Kalali AH, Buckley P; Treatment of schizoaffective disorder. Psychiatry (Edgmont). 2009 Mar6(3):15-7.
Schizoaffective Disorder; Royal College of Psychiatrists, 2015
Canuso CM, Turkoz I, Fu DJ, et al; Role of paliperidone extended-release in treatment of schizoaffective disorder. Neuropsychiatr Dis Treat. 2010 Oct 56:667-79. doi: 10.2147/NDT.S12612.
Leucht S, Helfer B, Dold M, et al; Carbamazepine for schizophrenia. Cochrane Database Syst Rev. 2014 May 25:CD001258. doi: 10.1002/14651858.CD001258.pub3.