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Acute exacerbation of chronic schizophrenia — Clinical Guidelines

Overview

An acute exacerbation of schizophrenia is a worsening of psychotic symptoms, such as hallucinations, delusions, and disorganized thinking, in an individual with a diagnosed schizophrenia spectrum disorder. This period often requires intensified treatment to regain symptom control and functional stability.

Diagnosis

Management

Antipsychotic maintenance therapy should be routinely offered 3.

For acute exacerbation, various antipsychotics have demonstrated dose-response relationships regarding discontinuation rates 1.

* Amisulpride, cariprazine, olanzapine, and quetiapine showed U-shaped curves, suggesting optimal dosing thresholds beyond which discontinuation rates may increase, potentially due to side effects 1. * Aripiprazole, asenapine, brexpiprazole, clozapine, paliperidone, and risperidone demonstrated plateau curves, indicating no additional benefit from increasing doses 1.

Long-acting injectable antipsychotics should be considered 3.

Cognitive behavioural therapy (CBT) for persistent positive and/or negative symptoms should be considered 3.

SSRI or SNRI add-on treatment for persistent negative symptoms should be used only cautiously 3.

Special Populations

Key Recommendations

Antipsychotic maintenance therapy should be routinely offered 3. (Evidence: Strong)

Long-acting injectable antipsychotics should be considered 3. (Evidence: Moderate)

Cognitive behavioural therapy for persistent positive and/or negative symptoms should be considered 3. (Evidence: Moderate)

References

1 Tian J, Siafis S, Lin X, Wu H, Schneider-Thoma J, Leucht S. Antipsychotic drug dosing and study discontinuation in schizophrenia: A systematic review and dose-response meta-analysis. European neuropsychopharmacology : the journal of the European College of Neuropsychopharmacology 2025. link 2 Barnes TR, Drake R, Paton C, Cooper SJ, Deakin B, Ferrier IN et al.. Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology. Journal of psychopharmacology (Oxford, England) 2020. link 3 Baandrup L, Østrup Rasmussen J, Klokker L, Austin S, Bjørnshave T, Fuglsang Bliksted V et al.. Treatment of adult patients with schizophrenia and complex mental health needs - A national clinical guideline. Nordic journal of psychiatry 2016. link

Acute exacerbation of chronic schizophrenia