Suicide and suicide attempts are higher in schizophrenic patients.

Consider compliance issues and substance use for exacerbations.

Neuroleptic malignant syndrome (NMS) is a medical emergency which can occur after administering antipsychotic medications:

• Altered mental status,
• Muscle rigidity,
• Hyperthermia, and
• Autonomic instability = hypertension or hypotension/tachycardia.
• Can cause rhabdomyolysis.
• Management includes stopping the culprit medication and supportive care (e.g., hydration, treat symptoms, monitor vitals and organ functioning) if this occurs.

• Schizophrenia is a disabling, chronic mental disorder that can present as psychosis, flattened affect, anhedonia, and disorganized thoughts/behaviours.
• The onset of schizophrenic symptoms late adolescence or early adulthood and can be abrupt or gradual.
• The main reasons for presentation:
  • Psychotic symptoms.
  • Agitation.
  • Related mental disorder: substance use disorder, anxiety, depression.
  • Physical disorder: acute injury, infection.

Schizophrenia is diagnosed clinically.

Table 1: DSM-V Criteria for Diagnosing Schizophrenia.

Associated signs and symptoms include cognitive deficits, reduced attention, irritable mood, impaired motor coordination, and left-right confusion.

Differential diagnoses to consider when a patient presents with the above symptoms include:

• Substance or medication-induced psychosis.
• Psychosis secondary to a medical condition (e.g., epilepsy, lupus, dementia, endocrine disorders, autoimmune disorders, neoplastic disorders).

Investigations to consider if initial presentation or acute change in behaviour:

• Complete blood count.
• Metabolic panel.
• Extended electrolytes.
• Drug and alcohol screening.
• TSH.
• C-Reactive Protein or ESR.
• Syphilis testing.
• CT head.
• +/- Lumbar puncture.
• +/- Electroencephalography (EEG).

Patients should receive a psychiatric evaluation rapidly which includes a risk assessment for suicide.

Acute agitation is treated as described in Clinical summaries:

• Management of agitated patient in the Emergency Department – Adult
• Treating Acute Agitation with Ketamine in the Emergency Department
• Management of Agitation or Aggression – Pediatric

Initiating antipsychotics:

Generally left for psychiatrists or family doctors. Some tips to consider when treating schizophrenia patients with antipsychotics:

• Lower dose recommended due to better treatment response and lower risk of adverse effects.
• Consider past treatments and patient preference.
• No consensus on which antipsychotic to administer or a precise dose.
• Adverse effects of medication include sedation, acute dystonia, akathisia (inability to stand still), parkinsonism (e.g., tremor, slow movement, rigidity, postural instability).

Consider for admission to psychiatry but if symptoms are mild and they are able to care for themselves with good family support and close follow-up, they may receive a comprehensive plan which includes follow-up with a Psychiatrist, social support services, therapy (e.g., cognitive behavioural therapy), assertive community treatment, and family support upon discharge.

Compliance with treatment is a protective factor for suicide risk; however, non-adherence is unfortunately common in schizophrenia patients.

1. https://emergencycarebc.ca/clinical_resource/acute-psychosis-diagnosis/

   https://emergencycarebc.ca/clinical_resource/neuroleptic-malignant-syndrome-diagnosis-treatment/

   https://emergencycarebc.ca/clinical_resource/suicide-risk-assessment/

   https://emergencycarebc.ca/clinical_resource/management-of-agitated-patient-in-the-emergency-department-adult/

   https://emergencycarebc.ca/clinical_resource/treating-acute-agitation-with-ketamine-in-the-emergency-department/

   https://emergencycarebc.ca/clinical_resource/management-of-agitation-or-aggression-pediatric/

   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4786236/

   https://www.sciencedirect.com/science/article/pii/S0163834399000031#aep-section-id24

   https://www.tandfonline.com/doi/abs/10.1080/17522439.2021.1912815

   
   

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