Treatment and Management of Schizophrenia and Schizophrenia-like syndromes

Establish a trusting therapeutic relationship with the patient; focus on empathizing with the distress that symptoms cause rather than reality orientation.
Encourage patients to maintain significant, supportive relationships.
Alleviate underlying physical causes.
Address identifiable psychosocial triggers.
Before using antipsychotic to treat behavioral symptoms for dementia, carefully assess for possible psychotic features (ie, delusions and hallucination and if psychotic symptoms are severe, frightening, or may affect safety).
For DSM-5, rate presence and severity (most severe in last 7 d) of psychotic symptoms (eg, hallucinations, delusions disorganized speech) on a 5-point scale ranging from 0 (not present) to 4 (present and severe).
Aripiprazole, olanzapine, quetiapine, and risperidone are first choice because of fewer adverse events (tardive dyskenesia [TD] extremely high in older adults taking first-generation antipsychotics).
Caution if history of falls or fractures.
All antipsychotics are associated with increased mortality in older adults.
Table 1 for representative medications for treatment of schizophrenia or schizophrenia-like syndromes, Table 2 for adverse events of second-generation antipsychotics, and Table 3 for management of adverse events of antipsychotic medications.
No studies are available to guide the duration of treatment with schizophrenia. Clinical experience suggests that patients who respond to antipsychotic medications should be continued on the minimal effective dosage for at least 6 mo. Patients with early-onset schizophrenia and chronic stable symptoms may be able to tolerate a gradual reduction in dosage of antipsychotic medication.
For all patients who relapse on treatment or when the dosage is lowered, maintenance over a longer term (at least 12 yr) is recommended.