Mental Health

Schizophrenia

A psychotic disorder diagnosed through longitudinal assessment of persistent psychosis, functional change and exclusion of mood, substance-related and medical causes, requiring urgent risk management and coordinated long-term care.

In a nutshell

Schizophrenia is a persistent psychotic disorder diagnosed through specialist longitudinal assessment, functional change and exclusion of mood, substance-related and medical causes. First-episode psychosis needs prompt early-intervention assessment. Treatment combines a shared antipsychotic trial with CBT and family intervention, systematic physical-health monitoring and a clear relapse plan; offer clozapine after two adequate antipsychotic trials that have not worked.

Classic presentation

A young adult develops persecutory delusions, external auditory hallucinations and disorganised thinking with declining self-care and function, requiring urgent specialist assessment and a medical and substance-use screen.

Key points

Psychosis is a syndrome: distinguish schizophrenia from affective psychosis, substance-related psychosis, delirium and neurological or endocrine disease.
Assess suicide, violence, command hallucinations, self-neglect, catatonia, capacity, safeguarding and dependants urgently.
Refer first-episode psychosis without delay to an early intervention in psychosis service; do not start antipsychotics in primary care without consultant psychiatrist involvement.
Offer an oral antipsychotic with individual CBT and family intervention; choose the medicine jointly after discussing metabolic, extrapyramidal, cardiovascular and hormonal adverse effects.
Record baseline weight, waist, pulse, blood pressure, glucose or HbA1c, lipids, prolactin, movement disorders, nutrition and activity; offer ECG when indicated.
Monitor response, adverse effects, movement disorders, adherence and physical health systematically; avoid routine antipsychotic polypharmacy and rapid neuroleptisation.
Review diagnosis, adherence, trial adequacy, substances and physical illness before clozapine; offer clozapine after two adequate antipsychotic trials have failed.
Clozapine requires specialist blood monitoring and active safety-netting for constipation, infection or fever, chest symptoms, seizures, smoking changes and other toxicity risks.

First-line investigation

Specialist mental-state and longitudinal assessment with collateral history, risk and safeguarding assessment, physical examination, medication and substance review, targeted medical investigations, and antipsychotic baseline cardiometabolic and movement-disorder checks.

Management

Assess psychosis and immediate risk

Assess suicide, violence, command hallucinations, self-neglect, catatonia, delirium, safeguarding and medical or substance causes; refer first-episode psychosis without delay to early intervention services.^1,2

Start the combined first-line pathway

Offer a shared oral antipsychotic trial with individual CBT and family intervention, using the BNF or product information for the agent, licensed range and interactions.^1,5,4

Monitor treatment and physical health

Record baseline and serial weight, waist, blood pressure, glucose or HbA1c, lipids, prolactin, movement disorders, adherence, response and subjective effects; offer ECG when indicated.^1,5

Review non-response and offer clozapine

Before clozapine, review diagnosis, adherence, adequate trial duration, substance use, interactions, physical illness and psychological treatment; offer clozapine after two adequate antipsychotic trials have failed.^1,5

Apply clozapine safety-netting

Use specialist blood monitoring and current UK clozapine protocols, and urgently assess fever or infection, severe constipation or abdominal pain, chest symptoms, collapse, seizures or major smoking changes.^5,6

Prevent relapse and support recovery

Maintain a collaborative care plan covering medication, early warning signs, crisis contacts, family or carer support, substances, smoking, physical health, housing, work and gradual medication changes.^1,4

Exam traps

A hallucination alone does not establish schizophrenia; assess the longitudinal syndrome, function, mood relationship and alternative causes.
Negative symptoms can resemble depression, but ask about mood, pleasure, motivation, cognition and psychosis separately.
Routine neuroimaging is not required for every first episode; investigate urgently when the presentation is atypical or neurological or medical features are present.
Clozapine follows inadequate response to two adequate antipsychotic trials, not simply one failed medicine or brief non-adherence.
Do not use routine antipsychotic polypharmacy or rapid neuroleptisation; document a monitored therapeutic trial.
Clozapine constipation can become life-threatening, while fever, sore throat, chest symptoms or collapse require urgent clinical assessment.
Do not stop antipsychotic treatment abruptly; if withdrawal is chosen, taper gradually and monitor for relapse.

Illustrations

Dopamine pathways in schizophreniaDiagram of the mesolimbic and mesocortical circuits as an explanatory model for positive versus negative and cognitive symptoms, with a note that schizophrenia is not explained by a single neurotransmitter pathway.PassFinals · original

Psychosis assessment and escalation pathwayFlow diagram from first presentation through risk assessment, medical and substance screening, early intervention referral, crisis escalation and specialist treatment.PassFinals · original

Treatment-resistant schizophrenia and clozapine pathwayDecision pathway showing shared antipsychotic trials, review of diagnosis and adherence, clozapine eligibility after two adequate trials, and ongoing blood and adverse-effect monitoring.PassFinals · original

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.