Trend Watch
disorder.
Treatment of
Schizoaffective Disorder
by Elisa Cascade; Amir H. Kalali, MD; and Peter Buckley, MD
ABSTRACT
In this article, we investigate the
range of treatments prescribed for
schizoaffective disorder. The data
show that the majority of those
treated, 87 percent, receive two or
more pharmaceutical classes. From
a therapeutic class perspective, 93
percent of schizoaffective disorder
patients receive an antipsychotic,
48 percent receive a mood disorder
patients with schizoaffective
Psychiatry (Edgemont) 2009;6(3):15–17
treatment, and 42 percent receive
an antidepressant. An expert
commentary is also included.
KEY WORDS
schizoaffective disorder,
antipsychotic, antidepressant
INTRODUCTION
In this article, we investigate the
range of treatments prescribed to
[VOLUME 6,
METHODS
We obtained data on product
treatment regimens from
SDI/Verispan’s Prescription Drug &
Diagnosis Audit (PDDA) database
from January 2008 to December
2008 for patients with
schizoaffective disorder as defined
by ICD-9 diagnosis code 295.7.
PDDA captures data on disease
states and associated therapy from
3,100 office-based physicians
representing 29 specialties across
the United States.
RESULTS
According to practice data from
SDI/Verispan, about one-half of
patients presenting with
schizoaffective disorder are women
and two-thirds are under the age of
50. Figure 1 displays the number of
classes of central nervous system
(CNS) agents typically prescribed
to treat schizoaffective disorder. As
seen in Figure 1, only 13 percent
are prescribed one class of
treatment. The majority receive
two classes (48%) or three
different classes (39%) of CNS
treatment.
The most common regimen for
the treatment of schizoaffective
disorder is antipsychotic only
(22%), followed closely by
antipsychotic + mood agent (20%);
antipsychotic + antidepressant
(19%); and antipsychotic + mood +
antidepressant (18%). All other
regimens have a prevalence of
three percent or lower.
From a therapeutic class
perspective, 93 percent of
schizoaffective disorder patients
receive an antipsychotic. Mood
disorder treatments and
antidepressants are the next most
commonly used CNS agents (48%
and 42%, respectively). Prevalence
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of sleep agent and antianxiety

treatment is six percent.

EXPERT COMMENTARY
by Peter Buckley, MD
These are interesting data and
should be considered in the context
of our current-day understanding of
schizoaffective disorder, a conditiion
originally described in the 1940s.
Schizoaffective disorder is a
contentious nosological entity. It
was originally conceived as a third,
independent entity alongside
schizophrenia and bipolar disorder.
Its course is intermediary and
considered to be more favorable
than schizophrenia. Some have
suggested that schizoaffective
disorder, depressive subtype,
resembles more schizophrenia in
course and treatment while
schizoaffective disorder, manic
FIGURE 1. Number of products used to treat schizoaffective disorder.
subtype, is more like a bipolar
Source: SDI/Verispan PDDA, Diagnosis 295.7, January 2008 to December 2008 disorder over time. However,
beyond some early, classic genetics
studies and some long-term
outcome studies, the aspects that
would set it apart as an independent
illness—namely biology, risk, course,
and treatment—have rarely been
studied with any methodological
rigor. In addition, pharmacological
studies do not focus on
schizoaffective disorder alone, and
what we know about the drug
treatment of schizoaffective
disorder comes from analyses of
large trials in patients with
schizophrenia that have included a
subset of patients with
schizoaffective disorder.
Another complicating factor is
that, in the absence of clearly
delineated features and course of
this condition, schizoaffective
disorder is apt to be
mis/overdiagnosed. For example, it
FIGURE 2. Classes prescribed to treat schizoaffective disorder. Note: Mood includes antiepileptics and is well known—and entirely
lithium, sleep includes sleep agents and trazodone, anxiety includes benzodiazepines and buspirone. logical—that people with
Source: SDI/Verispan PDDA, Diagnosis 295.7, January 2008 to December 2008. schizophrenia become depressed
over the course of their illness. This

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comorbidity, common in
schizophrenia,1 is ripe to be
misconstrued and then ‘labelled’ as
schizoaffective disorder. This can
easily happen as doctors often do
not have the time to go back over
years of course of illness so as to
meticulously chart the pattern of
mood symptoms in a patient with
chronic schizophrenia. Additionally,
in our mental health system,
patients are more likely to be
followed over time by several
doctors sequentially rather than to
have the same doctor for many
years. It is also observed that when
a diagnosis is made by one doctor, it
tends to be retained over time. So if
one doctor calls the patient’s illness
schizoaffective disorder, this
diagnosis will likely be carried
forward in care. When diagnostic
boundaries are complex and
blurred, this is another source of
variability on ascribing this
diagnosis.
Keeping the above comments in
mind, there are a number of
interesting observations from these
data. Firstly, the overwhelming
majority of patients are being
treated with antipsychotics. This
resonates well with the notion that
schizaffective disorder is related to
schizophrenia and falls within the
family of psychotic disorders. We
also note that only about 20 percent
of patients are receiving
antipsychotics alone. While this
polypharmacy is not a surprise, the
extent is a little higher than in most
studies of schizophrenia alone.2
Also, the pattern of polypharmacy
appears similar overall to that seen
in schizophrenia. There are no “ah-
ha’s” when you see these data, and I
would contend that these
pharmacovigilance data offer little
support for the idea that
schizoaffective disorder is really a
different condition from
schizophrenia.
So what does this all mean? The
status of schizoaffective disorder is
“up for grabs” in the review process
for the fifth edition of the
Diagnostic and Statistical
Manual of Mental Disorders
(DSM-V). It is not clear how to
position this condition, especially
since there is such a paucity of
biological and treatment studies to
inform evidence-based decisions
about the status of schizoaffective
disorder. I vote for abandoning the
concept altogether!
I think the field will be better
served by simplifying things. The
process for DSM-V will better serve
clinicians if it produces a DSM-V
that does not just “lump” or “split”
but also “takes out.” If
schizoaffective disorder was
removed, I believe there would be
little impact on treatment but
better diagnostic agreement among
clinicians.
People with schizophrenia who
experience depression would be
treated for their depression and
would not get “reclassified” to a
different diagnosis, as part of their
care. Many people with
schizophrenia get depressed.
Becoming depressed should not be,
by itself, a reason to change a
diagnosis of schizoaffective
disorder. There is some support for
removing schizoaffective disorder
from DSM nosology.4,5 Although the
data above are just that—data
about how clinicians prescribe
medications—they are interesting
and provide their own statement
about whether schizoaffective
disorder is really any different from
schizophrenia.
REFERENCES
1. Buckley PF, Miller B, Lehrer D,
Castle D. Comorbidities and
schizophrenia. Schizophr Bull.
2009 (in press).
2. Correll CU. Antipsychotic
[VOLUME
polypharmacy, part 1: shotgun
approach or targeted
cotreatment? J Clin Psychiatry.
2008;69(4):674–675.
3. Bora E, Yucel M, Fornito A, et al.
Major psychoses with mixed
psychotic and mood symptoms:
Are mixed psychoses associated
with different neurobiological
markers? Acta Psychiatr Scand.
2008;118(3):172–187.
4. Pierre J. Deconstructing
schizophrenia for DSM-V:
challenges for clinical and
research agenda. Clin Schizophr
Related Psychoses.
2008;2:166–174.
5. Lake CR, Hurwitz N.
Schizoaffective disorder: its rise
and fall: Perspectives for DSM-V.
Clinical Schizophrenia &
Related Psychoses.
2008;2(1):91–97.
AUTHOR AFFILIATIONS: Ms. Cascade is
Vice President, Quintiles Inc./iGuard, Falls
Church, Virginia; Dr. Kalali is Vice
President, Global Therapeutic Group
Leader CNS, Quintiles Inc., San Diego,
California, and Professor of Psychiatry,
University of California, San Diego; and Dr.
Buckley is Professor and Chairman,
Department of Psychiatry, Medical College
of Georgia, Augusta, Georgia.
ADDRESS CORRESPONDENCE TO:
Ms. Elisa Cascade, Vice President,
Quintiles, Inc./iGuard, 3130 Fairview Park
Drive, Suite 501, Falls Church, VA 22042;
E-mail: elisa.cascade@quintiles.com
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