How should I approach the management of a patient with schizoaffective disorder who is experiencing acute psychotic symptoms?

When a patient with schizoaffective disorder is experiencing acute psychotic symptoms, the primary approach involves prompt engagement with specialist mental health services for assessment and management.

• Immediate Action and Referral:
  • For an acute exacerbation or recurrence of psychosis, the patient should be offered oral antipsychotic medication or a review of existing medication, in conjunction with psychological interventions ³.
  • Crisis resolution and home treatment teams should be offered as a first-line service to support the person during an acute episode in the community, especially if the severity or level of risk to self or others exceeds the capacity of other community teams ³. These teams should be the single point of entry to all other acute services in the community and in hospitals ³.
  • Acute community treatment within crisis resolution and home treatment teams should be considered before admission to an inpatient unit ³.
  • Antipsychotic medication for a first presentation of sustained psychotic symptoms should not be started in primary care unless done in consultation with a consultant psychiatrist ³.
  • If a patient with a psychotic disorder is being managed solely in primary care, they should be re-referred to secondary care if there is a poor or partial response to treatment, poor treatment adherence, development of intolerable or medically important adverse effects from medication, suspected comorbid alcohol or drug misuse, or potential risk to the person or others ¹,².
• Secondary Care Management:
  • People diagnosed with a psychotic disorder are likely to be offered secondary care management ¹,². This includes a therapeutic trial of an oral antipsychotic (first-generation or second-generation) ¹,².
  • This pharmacological treatment is typically in conjunction with psychological interventions such as individual cognitive behavioural therapy (CBT) and family intervention ¹,²,³. Individual CBT should ideally consist of at least 16 planned sessions ¹,². Family intervention for relatives should ideally consist of 10 planned sessions over 3 months to 1 year ¹,².
  • Arts therapies may also be offered, particularly to help with negative symptoms ¹,².
• Care Planning and Support:
  • A comprehensive care plan should be in place, defining the roles of primary and secondary care, and include a crisis plan and an advance statement ¹,². A copy of this care plan should be sent to the primary care team ¹,².
  • The patient's family or carers should ideally be offered an initial assessment of their own needs by mental health services, a focused education and support programme, and should know where to obtain help during a crisis ¹,². They should also be aware of their right to a formal carer's assessment by social care services ¹,².
  • Monitoring of the person's health and the effects of antipsychotic drug treatment should occur for at least the first 12 months or until the condition has stabilised ¹,². During maintenance treatment, antipsychotic doses should not be reduced below the standard dose range recommended for acute stabilisation because reducing the dose further is associated with an increased risk of both relapse and all-cause discontinuation ¹,².