Schizoaffective disorder — diagnosis and management (MEQ)

(i) Diagnosis. Schizoaffective disorder, bipolar type. Justification: continuous illness with concurrent mood and Criterion A psychosis history; major mood episodes occupy the majority of total duration; clear intervals of delusions/hallucinations for more than 2 weeks without a major mood episode; lifetime mania establishes bipolar type; substance and medical causes do not fully account for the independent longitudinal pattern (cannabis is a comorbidity, not a complete alternative).[1]

(ii) Differentials with discriminators. Bipolar I with psychotic features — psychosis only during mood episodes (fails here because of euthymic psychosis fortnights). Schizophrenia with mood episodes — mood not majority of total duration (fails here). MDD with psychotic features — no mania and psychosis confined to depression. Cannabis-induced psychotic disorder — symptoms would not show multi-year independent polarity with repeated psychosis-without-mood off acute intoxication alone; still address dual diagnosis. Organic psychosis/delirium — unlikely without cognitive fluctuation/medical signs, but baseline work-up still required.[1][3]

(iii) Acute risk. Structured suicide assessment (intent, plan, means, command content, hopelessness, protective factors, substances). Means restriction. Consider urgent admission if command hallucinations to die and poor support/adherence. Capacity and least-restrictive legal pathway under local statute. Medical baseline: observations, bloods, ECG before intensifying meds. Crisis plan with family as privacy law allows. Do not discharge to an empty plan.[2][3]

(iv) Stepwise plan. Restart/optimise antipsychotic: if adherence is the problem, switch pathway toward paliperidone palmitate LAI (SAD maintenance evidence) after oral tolerability, or restart oral antipsychotic with supervised dosing (e.g. olanzapine titration toward 10–20 mg with metabolic monitoring, or paliperidone ER in the 6–12 mg trial range). For bipolar type, add mood stabiliser — lithium with baseline eGFR/TFT/ECG as indicated and 12-hour trough targets commonly 0.6–0.8 mmol/L maintenance (individualise), given anti-suicide signal in mood disorders; or continue antimanic SGA dual role. Do not use antidepressant monotherapy; if antidepressant later considered for residual depression, only with antipsychotic/mood-stabiliser cover and polarity vigilance. Cannabis cessation counselling. Family psychoeducation, CBTp access, sleep routine, vocational support. Metabolic monitoring schedule (BMI, glucose/HbA1c, lipids, BP).[3][4][6]

(v) Clozapine threshold. Enter clozapine if (a) high ongoing suicidal behaviour risk on the schizophrenia spectrum — InterSePT supports clozapine over olanzapine for suicidal behaviour including schizoaffective patients — and/or (b) treatment-resistant psychosis after two adequate adherent antipsychotic trials per TRRIP principles, with full haematological and physical monitoring infrastructure.[2][5]