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Treatment-Resistant Schizophrenia — MRCPsych Paper B MCQ

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EasySchizophrenia & PsychosisTreatment-Resistant SchizophreniaMRCPsych Paper B

A 32-year-old man with schizophrenia continues to experience prominent auditory hallucinations and persecutory delusions. The diagnosis has been reviewed, adherence confirmed, and substance use and relevant physical causes excluded. He has received sequential trials of risperidone and olanzapine, each for 6 weeks at an adequate licensed dose, without satisfactory improvement. What is the most appropriate next management step?

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Correct answer: E — Start clozapine

The correct answer is E, start clozapine. He has persistent psychotic symptoms despite sequential adequate trials of two different antipsychotics, both of which are non-clozapine second-generation agents. With adherence and alternative explanations for apparent non-response addressed, this meets the NICE threshold for treatment-resistant schizophrenia. Adding aripiprazole or using a supramaximal olanzapine dose should not precede an adequate clozapine trial. A long-acting injectable may be useful when preference or covert non-adherence is a concern, but it does not address confirmed pharmacological non-response. ECT is not recommended for the general management of schizophrenia; its principal relevant role is rapid short-term treatment of severe catatonia when other treatments have failed or the condition is life-threatening.

Reference: National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management (CG178), recommendations 1.5.7.2 and 1.5.7.4, 2014. https://www.nice.org.uk/guidance/CG178/chapter/recommendations