# Schizophrenia (Referral and Shared Care) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: eMC SmPC, Abilify 10 mg tablets (Otsuka), sections 4.1 and 4.2 · NICE CG178 Psychosis and schizophrenia in adults: prevention and management, 2014 (updated 2014) · Olanzapine 10 mg tablets SmPC section 4.2 (eMC product 3070) · Risperidone 2 mg Tablets SmPC section 4.2 (eMC product 11872) · Clozaril 25 mg Tablets SmPC sections 4.1, 4.2 and 4.4 (eMC product 4411) - Verified date: 2026-08 ## Verified against - NICE CG178 Psychosis and schizophrenia in adults: prevention and management, 2014 (updated 2014) - Olanzapine 10 mg tablets SmPC section 4.2 (eMC product 3070) - Risperidone 2 mg Tablets SmPC section 4.2 (eMC product 11872) - eMC SmPC, Abilify 10 mg tablets (Otsuka), sections 4.1 and 4.2 - Schizophrenia (Referral and Shared Care) - disease-level clinical article (schizophrenia-referral-full.txt) - Clozaril 25 mg Tablets SmPC sections 4.1, 4.2 and 4.4 (eMC product 4411) ## Treatment metadata - Urgent psychiatric referral and early intervention (No primary care drug initiation) - Olanzapine — 10 mg — oral.solid - Risperidone — 2 mg — oral.solid - Aripiprazole — 10 mg — oral.solid - Clozapine — oral.solid ## Complete treatment card ```text SCHIZOPHRENIA (REFERRAL AND SHARED CARE) Sources: eMC SmPC, Abilify 10 mg tablets (Otsuka), sections 4.1 and 4.2 · NICE CG178 Psychosis and schizophrenia in adults: prevention and management, 2014 (updated 2014) · Olanzapine 10 mg tablets SmPC section 4.2 (eMC product 3070) · Risperidone 2 mg Tablets SmPC section 4.2 (eMC product 11872) · Clozaril 25 mg Tablets SmPC sections 4.1, 4.2 and 4.4 (eMC product 4411) Review status: REVIEWED against NICE CG178 Psychosis and schizophrenia in adults: prevention and management, 2014 (updated 2014), Olanzapine 10 mg tablets SmPC section 4.2 (eMC product 3070), Risperidone 2 mg Tablets SmPC section 4.2 (eMC product 11872), eMC SmPC, Abilify 10 mg tablets (Otsuka), sections 4.1 and 4.2, Schizophrenia (Referral and Shared Care) - disease-level clinical article (schizophrenia-referral- full.txt), Clozaril 25 mg Tablets SmPC sections 4.1, 4.2 and 4.4 (eMC product 4411) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (4) - Patients may describe suicidal thoughts, plans, or past attempts, along with self-harm or aggressive urges [suicidal thoughts] - Command hallucinations telling the patient to act violently need specific screening [hallucinations] - Auditory hallucinations may take the form of voices that comment on what the patient is doing, or that talk to one another [hallucinations] - Thought broadcasting, insertion, or withdrawal may be described by the patient SIGNS - what you find (9) - Grooming and self-care are often poor, and dress may be unkempt or unusual - Behaviour can range from slowed movement to agitation, and the patient may be cooperative, withdrawn, or hostile [irritability · social withdrawal] - Catatonic features such as stupor, mutism, odd posturing, or gestures may be seen [mutism · stupor] - Speech can be disorganised, tangential, or incoherent, sometimes with invented words - Affect may be flat, blunted, or mismatched to what is being discussed, such as laughing about sad events - Fixed false beliefs, sometimes bizarre and implausible, may be elicited on exam [delusions] - Thought process may show loose associations, illogical links, or a sudden stop mid-sentence - Auditory hallucinations are the most frequent perceptual disturbance, though any sensory modality can be affected [hallucinations] - Insight and judgement are often impaired, ranging from partial awareness to none at all TESTS (11) - No laboratory, imaging, or psychometric test diagnoses schizophrenia on its own - A full blood count screens for anaemia or infection mimicking psychiatric illness; neutrophil count is tracked around clozapine use - Thyroid function is checked, since an underactive thyroid can mimic depression and cognitive impairment - Baseline work-up includes a pregnancy test in women who could conceive - An EEG may be needed if history or exam raises concern for a seizure disorder - Brain MRI, favoured over CT, may be ordered when the neurological exam or history is concerning - An RPR screens for syphilis, and HIV testing is worthwhile, since either can mimic psychiatric illness - An ECG is obtained before starting certain higher-risk antipsychotics, especially with cardiac risk factors or a raised baseline QTc - The AIMS or DISCUS scale tracks abnormal movements at baseline and every 6 to 12 months on antipsychotics - PANSS grades symptom severity and tracks improvement over time - BPRS is an 18-item scale assessing positive, negative, and affective symptoms of psychosis IF NOT THIS - what else fits (9) - Depressive or bipolar disorder with psychotic features is favoured when hallucinations or delusions occur only during a mood episode - Schizoaffective disorder needs concurrent mood episodes with active-phase symptoms, the mood component present for most of that phase - Schizophreniform disorder runs under 6 months, while brief psychotic disorder spans a day to under a month - Delusional disorder lacks the pronounced hallucinations or disorganised speech seen in schizophrenia - Schizotypal personality disorder shows subthreshold psychotic features on top of a lasting personality pattern - OCD or body dysmorphic disorder centres on intense preoccupations that can occasionally reach delusional intensity - PTSD rests on a specific traumatic event and symptom pattern, though flashbacks and hypervigilance can look paranoid - Autism and communication disorders are marked by social-interaction deficits and repetitive behaviour rather than true psychosis - Substance-induced or delirium-related psychosis is favoured when symptoms are not persistent and trace to a substance or medical cause Source StatPearls "Schizophrenia" - disease-level clinical article Status traced to the source above Rx: Main treatment | Treatment-resistant schizophrenia only - registered monitoring service, psychiatry-initiated MAIN TREATMENT - choose one 1. URGENT PSYCHIATRIC REFERRAL AND EARLY INTERVENTION (NO PRIMARY CARE DRUG INITIATION)[1st line] Adult Refer all patients with suspected first-episode psychosis or acute psychotic relapse urgently to secondary care mental health services (Early Intervention in Psychosis / Crisis Team). Antipsychotic treatment should be initiated by a specialist psychiatrist after baseline metabolic, cardiovascular, and neurological assessment. - Immediate urgent referral Peds Children and adolescents <18 years with suspected psychosis require emergency referral to child and adolescent mental health services (CAMHS). Source NICE CG178 Psychosis and schizophrenia in adults: prevention and management, 2014 (updated 2014) Why NICE CG178 1.3.2.1 is a bar, not a preference: antipsychotic medication must not be started in primary care at a first presentation of psychotic symptoms that have been sustained, unless the decision is taken in consultation with a consultant psychiatrist. NG181 covers rehabilitation for complex psychosis and contains no such rule; the row's own dose_source already named CG178. Caution Do not initiate antipsychotics in primary care for unconfirmed first-episode psychosis prior to specialist assessment unless advised by secondary care. Evaluate for organic causes of acute psychosis: drug toxicity/withdrawal, intracranial lesions, encephalitis, neurosyphilis, thyroid dysfunction, and systemic infection. Assess risk of harm to self or others; if severe agitation, command hallucinations, or acute risk is present, arrange emergency psychiatric admission under mental health legislation. RED FLAG - Neuroleptic malignant syndrome is a medical emergency requiring immediate cessation of all antipsychotics and transfer to a higher level of care. 2. OLANZAPINE [2nd line] Adult 5-10 mg once daily at bedtime initially, titrate in steps of 5 mg daily at intervals of at least 1 week to target 10-20 mg once daily (max 20 mg daily) under shared-care protocol - long-term (specialist supervision) Peds Specialist child and adolescent psychiatry initiation only. Source Olanzapine 10 mg tablets SmPC section 4.2 (eMC product 3070) Why First-line atypical antipsychotic for maintenance therapy in shared care following specialist initiation. Caution High risk of metabolic syndrome: substantial weight gain, dyslipidemia, insulin resistance, and new-onset diabetes. Monitor baseline and periodic weight, fasting blood glucose, lipid profile, and blood pressure. Do not abruptly stop therapy due to risk of rapid psychotic relapse and severe withdrawal symptoms. The label starts at 10 mg a day and allows increases at intervals of not less than 24 hours, within a range of 5-20 mg. The slower start and weekly steps above are a deliberate primary-care choice, not the licence - a psychiatrist titrating an inpatient will move faster. Egypt INTEGROL 10 MG 30 F.C. TABS. GLOBAL NAPI P... 117.00 EGP (3.90/unit) BIOPREX 10 MG 30 F.C.TABS. SAJA PHARMACE... 195.00 EGP (6.50/unit) OLAZORIX 10 MG 30 F.C.TABS. MASH PREMIERE 201.00 EGP (6.70/unit) OLAPEX 10 MG 30 F.C.TABS. MULTI-APEX 234.00 EGP (7.80/unit) OLAZINE 10MG 7 SCORED F.C.TAB. EIPICO 35.00 EGP SCHISOLAZINE 10 MG 30 ORODISPERSIBLE TABS. WADI ELNEEL BENTA > PHARCO 234.00 EGP PREXAL 10 MG 30 CAPLETS JOSWE MEDICAL... 316.00 EGP ZYPREXA VELOTAB 10 MG 28 ORODISPERDIBLE TABS. CATALENT UK SWIDON ZYDIS L... 1001.00 EGP 3. RISPERIDONE [2nd line] Adult 2 mg daily in 1-2 divided doses initially, increase on day 2 to 4 mg daily; usual maintenance dose 4-6 mg daily (max 16 mg daily) under shared-care protocol - long-term (specialist supervision) Peds Specialist child psychiatry initiation only. Source Risperidone 2 mg Tablets SmPC section 4.2 (eMC product 11872) Why Alternative second-generation antipsychotic for shared-care maintenance. Caution Dose-dependent extrapyramidal side effects (parkinsonism, dystonia, akathisia) and hyperprolactinaemia. Increased mortality and stroke risk in elderly patients with dementia-related psychosis. Elderly: start at 0.5 mg twice daily and step up by 0.5 mg twice daily to 1-2 mg twice daily. Not the adult 2 mg start. Renal or hepatic impairment: halve both the starting dose and every step after it, and titrate slower. Above 10 mg a day there is no evidence of better effect, only more side effects. 16 mg is untested. Egypt ITORISPERIDONE 2MG 30 F.C. TABS. SIGMA > INTER... 48.00 EGP (1.60/unit) SCHIZODAL 2MG 10 F.C.TAB. EL-OBOUR 24.00 EGP (2.40/unit) RISPERIDONE 2MG 10 F.C.TAB. PHAROPHARMA 26.00 EGP (2.60/unit) RISCURE 2 MG 20 F.C. TAB. GLOBAL NAPI P... 73.00 EGP (3.65/unit) APEXIDONE 2MG 20 F.C.TAB. APEX PHARMA 75.00 EGP (3.75/unit) PSYCHODAL 2MG 30 F.C.TAB. DELTA PHARMA 171.00 EGP (5.70/unit) PSYCHODAL 2 MG 10 ORAL DIS.TAB. DELTA PHARMA 43.00 EGP CLAVIPERDONE 2 MG 30 ORALLY DISINT. TABS. NAPCO PHARMA > CLAVITA PHARMA 115.50 EGP NEROSCHIZ 1MG/ML SYRUP 30 ML DEBEIKY > PHA... 10.50 EGP -> ? strength differs, ? different route - not oral solid SCHIZOPERDAL 1MG/ML SYRUP 30ML GRAND PHARMA ... 18.00 EGP -> ? strength differs, ? different route - not oral solid 4. ARIPIPRAZOLE [2nd line] Adult 10 mg or 15 mg once daily to start; recommended maintenance 15 mg once daily; effective range 10-30 mg daily, maximum 30 mg daily - Long-term under psychiatric shared care Peds 15 years and over: 2 mg (as oral solution) for 2 days, then 5 mg for 2 days, then the 10 mg daily target. Not recommended below 15 years for schizophrenia. (Adolescents 15 years and over with schizophrenia: 2 mg (as oral solution) for 2 days, then 5 mg for 2 days, then the 10 mg/day target. Not recommended below 15 years for schizophrenia. Fixed milligram titration, not weight-based.) Choice Alternatives, all second-generation antipsychotics in shared care. Aripiprazole has the least metabolic burden of the three and 46 Egyptian products stock it. Source eMC SmPC, Abilify 10 mg tablets (Otsuka), sections 4.1 and 4.2 Why 46 live products - the second most prescribed atypical antipsychotic on the Egyptian market after olanzapine. Distinctly less weight gain and metabolic disturbance than the olanzapine already listed, and less hyperprolactinaemia than the risperidone, which is why patients get switched onto it. Caution Initiation is a psychiatrist's decision - this condition is a referral pathway and the GP role is continuation, monitoring and relapse detection. Akathisia is common (12.1% versus 3.2% on placebo) and is regularly mistaken for worsening psychosis or anxiety. Ask directly about inner restlessness and an inability to sit still. Impulse control disorders - pathological gambling, hypersexuality, compulsive shopping and binge eating. Ask the family; patients rarely volunteer it. Reduce the dose or stop if it appears. There is increased mortality in elderly patients with dementia-related psychosis - aripiprazole is not for behavioural symptoms of dementia. Still monitor weight, waist, fasting glucose and lipids, even though the metabolic risk is lower than with olanzapine. A strong CYP3A4 inhibitor or a CYP2D6 inhibitor requires the dose to be halved; a CYP3A4 inducer such as carbamazepine requires it to be doubled. Watch for hyperglycaemia symptoms: polydipsia, polyuria, polyphagia and weakness. Egypt ADWIPRAZOLE 10MG 30 F.C. TAB. ADWIA 90.00 EGP (3.00/unit) APILIPEX 10 MG 30 F.C.TAB. MULTI-APEX 90.00 EGP (3.00/unit) ARIPIPRACARE 10 MG 30 TABS. MULTICARE 90.00 EGP (3.00/unit) CENTALIFY 10 MG 10 TAB. HIKMA PHARMA 45.00 EGP (4.50/unit) ARIPIPRAZOLE 10 MG 20 F.C. TAB. EL-OBOUR > IN... 99.00 EGP (4.95/unit) ARIPIPREX 10MG 30 F.C.TAB. SIGMA > ANDAL... 162.00 EGP (5.40/unit) ARIPIPRAZOLE 10 MG 20 ORALLY DISINT. TABS. EL-OBOUR > PROTECH PHARMA 89.75 EGP SCHIZOFY 10MG 20 SCORED F.C.TAB. WESTERN PHARM... 114.00 EGP ARIPIPREX 1MG/ML ORAL SOL. 100 ML SIGMA > ANDALOUS PHARMA 44.00 EGP -> ? strength differs, ? different route - not oral solid ARIPIPRAZOLE 1MG/ML ORAL SOL. 120 ML ATCO PHARMA > INSPIRE PHARMACEUTICA... 46.00 EGP -> ? strength differs, ? different route - not oral solid TREATMENT-RESISTANT SCHIZOPHRENIA ONLY - REGISTERED MONITORING SERVICE, PSYCHIATRY-INITIATED 5. CLOZAPINE [3rd line] Adult Started tiny and climbed slowly. SmPC verbatim: "12.5 mg once or twice on the first day, followed by 25 mg once or twice on the second day. If well tolerated, the daily dose may then be increased slowly in increments of 25 to 50 mg in order to achieve a dose level of up to 300 mg/day within 2 to 3 weeks. Thereafter, if required, the daily dose may be further increased in increments of 50 to 100 mg at half-weekly or, preferably, weekly intervals." Therapeutic range verbatim: "In most patients, antipsychotic efficacy can be expected with 200 to 450 mg/day given in divided doses." Ceiling verbatim: increments "not exceeding 100 mg" are permissible "up to 900 mg/day", with "the possibility of increased adverse reactions (in particular seizures) occurring at doses over 450 mg/day" borne in mind. Nothing is started unless the count allows it: the SmPC restricts initiation to patients whose white cell count is at least 3,500 per cubic millimetre and whose absolute neutrophil count is at least 2,000 per cubic millimetre, both within normal limits. - Six months at least, then reviewed downward. SmPC verbatim: "Treatment should be maintained for at least 6 months." Stopping is gradual - "a gradual reduction in dose over a 1 to 2-week period is recommended." Peds Not a paediatric prescription. SmPC verbatim: "The safety and efficacy of Clozaril in children and adolescents under the age of 16 years have not yet been established. It should not be used in this group until further data become available." Source Clozaril 25 mg Tablets SmPC sections 4.1, 4.2 and 4.4 (eMC product 4411) Why The disease article states the indication twice, verbatim: "For these patients, clozapine is the recommended treatment option, with about 40% of those with treatment- resistant schizophrenia responding." and "Clozapine is also recommended for patients with schizophrenia with persistent, substantial risks of suicide or aggression despite other treatments." The SmPC's indication section names the same patient, verbatim: "Clozaril is indicated in treatment-resistant schizophrenic patients and in schizophrenia patients who have severe, untreatable neurological adverse reactions to other antipsychotic agents, including atypical antipsychotics." It sits at line 3 because resistance is defined by what came before it, the article's own definition being persistent symptoms "despite 2 or more trials of antipsychotic medications at adequate doses and durations, with documented adherence." Fourteen Egyptian products are registered, ZACLO 100 mg at 19.20 EGP through LEPONEX; the blood monitoring, not the price, is what limits its use. Caution RED FLAG - agranulocytosis. Any fever, sore throat or flu-like illness on clozapine is an urgent full blood count the same day, not a wait-and-see. SmPC verbatim: "Clozaril can cause agranulocytosis." The blood count schedule is a condition of prescribing, not advice. SmPC verbatim: regular white cell and absolute neutrophil counts "weekly during the first 18 weeks of treatment, and at least every 4 weeks thereafter throughout treatment. Monitoring must continue throughout treatment and for 4 weeks after complete discontinuation". Contraindicated in anyone who cannot be monitored. SmPC verbatim: "Patients unable to undergo regular blood tests." and "History of toxic or idiosyncratic granulocytopenia/agranulocytosis". Cardiac assessment before the first dose. SmPC verbatim: "Patients with history of cardiac illness or abnormal cardiac findings on physical examination should be referred to a specialist for other examinations that might include an ECG, and the patient treated only if the expected benefits clearly outweigh the risks". Myocarditis in the first weeks is the classic presentation. DRESS ends the drug permanently. SmPC verbatim: "If the patient has developed DRESS with the use of clozapine, treatment with clozapine must not be restarted in this patient at any time." Two days off and the titration restarts from the beginning. SmPC verbatim: "In patients in whom the interval since the last dose of Clozaril exceeds 2 days, treatment should be re-initiated with 12.5 mg given once or twice on the first day." A missed weekend is a real hazard, not a technicality. Seizure risk rises with dose, and constipation on clozapine can progress to bowel obstruction - both are asked about at every review. Egypt SCHIZONEX 25 MG 50 TAB. PHARCO 26.00 EGP (0.52/unit) MEDAZEPINE 25MG 50 TAB. WESTERN PHARM... 28.50 EGP (0.57/unit) ZACLO 25 MG 10 TAB. DELTA PHARMA 6.00 EGP (0.60/unit) CLOZAPINE 25MG 30 TAB. COPAD PHARMA 36.00 EGP (1.20/unit) SCHIZONEX 100 MG 50 TAB. PHARCO 76.00 EGP (1.52/unit) CLOZAVITONE 100 MG 20 F.C. TABS. MEDIZEN PHARM... 52.00 EGP (2.60/unit) LEPONEX 100MG 50 TAB. NOVARTIS > MYLAN 207.50 EGP (4.15/unit) CLOZAPINE 100MG 30 SCORED TAB. BIORIGINAL IN... 93.00 EGP Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)