Evidence-Based Reviews

Schizoaffective disorder: Which symptoms should be treated first?

Current Psychiatry. 2003 January;2(1):22-29

References

1. Kasanin J. The acute schizoaffective psychoses. Am J Psychiatry 1933;113:97-126.

2. Kraepelin E. Dementia praecox and paraphrenia, together with manic depressive insanity. Translated from original texts by The Classics of Psychiatry and Behavioral Sciences Library. Delran, NJ; Gryphon Editions, 1993.

3. Bleuler E. Text-book of psychiatry. Translated from original texts by The Classics of Psychiatry and Behavioral Sciences Library. Delran, NJ: Gryphon Editions, 1994.

4. Keck PE, Jr, McElroy SL, Strakowski SM/, West SA. Pharmacologic treatment of schizoaffective disorder. Psychopharmacology 1994;114:529-38.

5. Diagnostic and statistical manual of mental disorders. Washington, DC: American Psychiatric Association, 1952.

6. Diagnostic and statistical manual of mental disorders (2nd ed). Washington, DC: American Psychiatric Association, 1968.

7. Diagnostic and statistical manual of mental disorders (3rd ed). Washington, DC: American Psychiatric Association, 1980.

8. Spitzer RL, Endicott J, Robins E. Research diagnostic criteria. Rationale and reliability. Arch Gen Psychiatry 1978;35:773-82.

9. Pope HG, Jr, Lipinski JF. Diagnosis of schizophrenia and manic-depressive illness: a reassessment of the specificity of ‘schizophrenic’ symptoms in the light of current research. Arch Gen Psychiatry 1978;35:811-28.

10. Strakowski SM, McElroy SL, Keck PE, Jr, West SA. Racial influence on diagnosis in psychotic mania. J Affect Disord 1996;39:157-62.

11. Diagnostic and statistical manual of mental disorders (3rd ed, rev). Washington, DC: American Psychiatric Press, 1987.

12. Diagnostic and statistical manual of mental disorders (4th ed). Washington, DC: American Psychiatric Press, 1994.

13. Keck PE, Jr., McElroy SL, Strakowski SM. New developments in the pharmacologic treatment of schizoaffective disorder. J Clin Psychiatry 1996;57S:41-8.

14. Clayton PJ. Schizoaffective disorders. J Nerv Ment Dis 1982;170:646-50.

15. Kendler KS, Spitzer RL, Williams JBW. Psychotic disorders in DSM-III-R. Am J Psychiatry 1989;146:953-62.

16. Strakowski SM, Keck PE, Jr, Sax KW, McElroy SL, Hawkins JM. Twelve-month outcome of patients with DSM-III-R schizoaffective disorder: comparisons to matched patients with bipolar disorder. Schizophrenia Res 1999;35:167-74.

17. Maier W, Lichtermann D, Minges J, Heun R, Hallmayer J, Benkert O. Schizoaffective disorder and affective disorders with mood-incongruent psychotic feathers: keep separate or combine? Evidence from a family study. Am J Psychiatry 1992;149:1666-73.

18. Kendler KS, McGuire M, Gruenberg AM, Walsh D. Examining the validity of DSM-III-R schizoaffective disorder and its putative subtypes in the Roscommon Family Study. Am J Psychiatry 1995;152:755-64.

19. Crow TJ. A continuum of psychosis, one human gene and not much else—the case for homogeneity. Schizophrenia Res 1995;17:135-45.

20. Strakowski SM, DelBello MP, Adler CM. Comparative tolerability of drug treatments for bipolar disorder. CNS Drugs 2001;15:701-18.

21. Strakowski SM. Diagnostic validity of schizophreniform disorder. Am J Psychiatry 1994;151:815-24.

Patient management

When faced with a patient who meets criteria for schizoaffective disorder, I believe practical considerations can guide treatment. The label “schizoaffective disorder” reminds us to consider treatment of these patients broadly (in contrast, for example, to the label “schizophreniform disorder,” which implies a stronger link to schizophrenia than outcome studies support²¹).

Treat the mood component first. In most patients with schizoaffective disorder, it is difficult to distinguish between diagnoses of schizophrenia or mood disorder. It is prudent to begin by aggressively treating the mood component, because psychotic mood disorders generally respond more favorably to treatment than does schizophrenia. Use mood stabilizers for patients with a history of mania and antidepressants in depressed patients with no history of mania.

As is true for psychotic mood disorders, concurrent administration of an antipsychotic is often warranted. Recent studies strongly suggest that atypical antipsychotics are preferred over traditional neuroleptics to treat psychotic patients in general, and this preference extends to patients with schizoaffective disorder.^4,14,20

Some—if not most—atypical antipsychotics may have mood-stabilizing or antidepressant properties and may permit monotherapy of patients with schizoaffective disorder. Controlled clinical trials have not examined these agents as long-term maintenance therapy for the mood component of schizoaffective disorder, however. Until such studies are completed, many patients may require long-term mood-stabilizer or antidepressant therapy, with or without ongoing antipsychotic treatment.^4,14

The next step. Alternate treatments should be considered for patients in whom trials of atypical antipsychotics have failed, both in combination with thymoleptics and in monotherapy. Conventional antipsychotics, particularly depot formulations, are a reasonable intervention, particularly in schizoaffective patients with minimal mood symptoms.

Clozapine remains a first-line choice for patients with treatment-resistant psychotic disorders and should be considered in patients with treatment-resistant schizoaffective disorder as well.

Conclusion

Patients meeting criteria for schizoaffective disorder typically present with a complex and confusing combination of affective and psychotic symptoms. The diagnosis continues to be applied predominantly to patients who are otherwise difficult to classify, and the diagnostic criteria supporting the presence of a distinct condition remain poorly validated.

Schizoaffective disorder probably defines a heterogeneous group of patients, but—practically speaking—they can often be managed by following algorithms for psychotic mood disorders.^4,13 The most prudent long-term approach seems to be to keep treatment options flexible, with careful attention to managing symptoms as they wax and wane, rather than rigidly fixing on a single medication or type of medication.

Related resources

National Mental Health Association factsheet on schizoaffective disorder www.nmha.org/infoctr/factsheets/52.cfm
Reichenberg A, Weiser M, Rabinowitz, J, et al. A population-based cohort study of premorbid intellectual, language, and behavioral functioning in patients with schizophrenia, schizoaffective disorder, and nonpsychotic bipolar disorder. Am J Psychiatry 2002;159(12):2027-35.
Robinson DG, Woerner, MG, Alvir JM, et al. Predictors of medication discontinuation by patients with first-episode schizophrenia and schizoaffective disorder. Schizophr Res 2002;57(2-3):209-19.