Management of Aggressive and Combative Behavior in Schizoaffective Disorder

Medication Recommendations

The American Academy of Family Physicians recommends adding quetiapine (Seroquel) to the current medication regimen for a patient with schizoaffective disorder, starting at 12.5 mg twice daily and titrating up to 200 mg twice daily as needed, due to its efficacy in controlling aggressive behavior and more sedating properties beneficial for agitation and combativeness 1
The American Academy of Child and Adolescent Psychiatry suggests optimizing valproate (Depakote) dosing, with a current dose of 20 mg TID being significantly below therapeutic range, and recommends increasing to 125 mg BID initially, then titrating to therapeutic blood level (40-90 mcg/mL), as valproate has demonstrated efficacy for controlling aggressive behavior 2, 3

Consider tapering and discontinuing olanzapine once quetiapine reaches therapeutic dose, to reduce unnecessary polypharmacy and decrease risk of metabolic side effects, as recommended by the American Academy of Child and Adolescent Psychiatry 1, 2

Monitor for orthostatic hypotension during initial titration of quetiapine, and check valproate blood levels to ensure therapeutic range (40-90 mcg/mL), as recommended by the American Academy of Family Physicians 1
Assess response of aggressive and combative behaviors within 1-2 weeks of medication changes, as suggested by the American Academy of Child and Adolescent Psychiatry 3

Avoid rapid addition of multiple medications without assessing response to each change, and beware of excessive sedation when combining multiple antipsychotics and mood stabilizers, as recommended by the American Academy of Family Physicians and the American Academy of Child and Adolescent Psychiatry 1, 3
Avoid benzodiazepines as first-line treatment for agitation in elderly patients due to risk of paradoxical reactions and cognitive impairment, as recommended by the American Academy of Family Physicians 4