Schizophrenia is usually treated with a combination of medication and therapy, tailored to the individual.

Psychological interventions

Psychological factors play an important role in schizophrenia, so interventions such as cognitive behavioural therapy (CBT) and family intervention should be used alongside oral antipsychotic medication. 

Family intervention should be offered to all families who live with or who are in close contact with the patient, particularly those who have recently relapsed, are at risk of relapse or have persisting symptoms. Arts therapies should be offered to all people with psychosis or schizophrenia, particularly for the alleviation of negative symptoms.

Antipsychotics

Antipsychotics are used for the treatment of acute episodes and for relapse prevention. They are available as an oral pill or an injection known as a depot. They are more effective at alleviating positive symptoms.

The affinity of antipsychotics at histamine, serotonin, muscarinic and alpha-adrenergic receptors gives rise to side effects such as sedation, weight gain, blurred vision, dry mouth, constipation and postural hypotension. Due to their differing potency and affinity at these receptors, antipsychotics have very different side effect profiles. 

The effectiveness of antipsychotics (with the exception of clozapine) has been shown to be the same. Choice of antipsychotic should therefore take into account the likely benefits and possible side effects of each drug. 

The choice of antipsychotic medication should be made together by the service user and the healthcare professional, with the views of the carer taken into account if the service user agrees. The decision should be based on the likely benefits and possible side effects of each drug, including:

• Metabolic (e.g. weight gain and diabetes)
• Extrapyramidal (movement disorders)
• Cardiovascular (e.g. heart rhythm disturbances)
• Hormonal (e.g. increasing plasma prolactin, which causes breast milk production)
• Other (e.g. unpleasant subjective experiences). 

In the UK, clozapine is licensed for use in people with €treatment-resistant€ schizophrenia €“ defined as a €lack of satisfactory clinical improvement despite the use of adequate doses of at least two different antipsychotic agents, including an atypical antipsychotic agent, prescribed for adequate duration€.

Routine monitoring is a must with clozapine because of the risk of neutropenia and agranulocytosis, which cause an increased sensitivity to infection. Regular blood tests are required and dispensing must not occur without a €valid€ blood test. Prescribers and pharmacists must be registered with the manufacturer of the different brands (Clozaril, Denzapine and Zaponex) in order to be able to dispense clozapine. 

Due to a high occurrence of side effects, clozapine is slowly titrated (increased) to a treatment dose. A break in treatment of over 48 hours requires re-titration due to the increased risk of seizures, cardiac issues and enhanced sedation. 

Depots or long-acting injectable (LAI) antipsychotics 

These are administered by deep intramuscular injection every few weeks. They are slowly released from the injection site, giving relatively stable plasma drug levels over long periods. They often increase drug adherence but have a lack of flexibility of administration.