Aims and approach to treatment

Although most data that inform advice in this topic come from studies conducted in people with schizophrenia, this topic is intended to apply to all psychotic disorders. It is reasonable to extrapolate the data from schizophrenia because psychosis spectrum disorders respond to similar treatments and there is a lack of evidence for targeted treatment.

The aims of treating psychoses including schizophrenia are to:

• facilitate recovery
• prevent relapse, because repeated relapses are associated with poor short- and long-term outcomes
• improve function, quality of life and physical health
• prevent suicide¹.

To achieve these aims, use a multifaceted treatment approach that is individualised based on:

• patient factors, including age, psychosocial maturity (see here for considerations in young people), sex, childbearing potential (see Considerations in treating psychoses including schizophrenia in females of childbearing potential or Consideration in treating psychoses including schizophrenia in the perinatal period), ethnicity, personality, coping style, cognitive abilities, natural aptitudes, living situation, medical risk factors (including family history and problem substance use) and sociocultural environment
• the psychotic disorder being treated, including
  • schizophrenia
  • schizoaffective disorder
  • substance-induced psychosis
  • delusional disorder
• stage of illness (eg first episode, recovery, relapse)
• speed at which symptoms and signs resolve with treatment.

Multifaceted treatment over the first 5 years maximises recovery, but continued access to a range of interventions appears to be necessary to maintain this effect². Although treatment should be individualised, the following should always be components of treatment:

• care delivered by a multidisciplinary team, including a general practitioner, psychiatrist, mental health nurse, clinical psychologist, occupational therapist, social worker and, if available, an exercise physiologist and peer workers—shared care improves health outcomes for people with psychotic disorders. Members of the multidisciplinary team should:
  • foster a therapeutic alliance with the patient using supportive psychotherapeutic strategies (eg actively engaging with the patient by listening attentively to their worries and concerns, and responding effectively and empathically)
  • instil the patient with realistic optimism
  • help the patient and, if they consent, their family, carers or significant others understand the disorder and the patient’s early signs and symptoms of relapse—see Psychoeducation
  • ensure continuity and quality of care—clinicians who have a close relationship with the patient may be more likely to notice signs of relapse
• psychosocial interventions, which are more effective than antipsychotics in the treatment of cognitive and negative symptoms³
• antipsychotic therapy to reduce positive and negative symptoms and excitement, prevent relapse and reduce mortality. For adults and young people, see:
  • oral regimens for a first episode of psychosis, here
  • approach to antipsychotic therapy for recovery and relapse prevention, here
  • long-acting injectable regimens, here
  • approach to antipsychotic therapy for relapse treatment, here
  • approach to therapy (including clozapine) for treatment-resistant schizophrenia, here
• strategies to monitor for, prevent and address antipsychotic adverse effects
• strategies to maintain physical health
• identification and treatment of comorbidities
• support for families, carers or significant others
• a relapse prevention strategy.

It is particularly important to actively engage with a patient who has psychosis because the disorder can impair their insight, motivation and cognition. Care may need to be assertively provided with the assistance of a community mental health team.

Patient resources include:

• for young people, Headspace
• Head to health
• Lifeline (13 11 14)
• SANE Australia
• Suicide Call Back Service (1300 659 467).