Chronic psychoses — MSF Clinical guidelines

What this guideline says

GMJ summary

This MSF clinical guideline provides comprehensive pharmacological management protocols for chronic psychoses, particularly schizophrenia, characterized by delusions, hallucinations, disorganized thinking, and impaired social functioning. The guidance emphasizes monotherapy with antipsychotics, starting at low doses and titrating to the minimum effective dose, with treatment duration of at least one year and possibly lifelong for schizophrenia patients.

Haloperidol is recommended as first-line therapy, starting at 0.5 mg twice daily and gradually increasing to a maximum of 15 mg daily. Alternative antipsychotics include risperidone, chlorpromazine, and olanzapine. For long-term management, the guideline supports transition to long-acting injectable haloperidol decanoate once patients are stabilized on oral therapy. Special protocols are provided for managing acute agitation, extrapyramidal symptoms, and treatment in pregnant or breastfeeding women.

The guideline stresses the importance of excluding organic causes and substance use before initiating antipsychotics, recording baseline vital signs and weight, and providing treatment even when long-term follow-up is uncertain, though cautioning against starting pharmacotherapy in patients without family or social support unless severe behavioral disorders are present.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Haloperidol PO is first-line: start 0.5 mg twice daily for 3 days, then 1 mg twice daily for week 1, increase to 2.5 mg twice daily week 2; maximum 15 mg daily
2. Risperidone PO alternative: 1 mg twice daily week 1, then 2 mg twice daily week 2, increase to 3 mg twice daily week 3 if needed; maximum 10 mg daily
3. Chlorpromazine PO for sedation: start 25–50 mg once daily evening for week 1, titrate up to 100 mg three times daily; maximum 300 mg daily
4. For extrapyramidal symptoms: reduce antipsychotic dose or add biperiden PO 2 mg once daily, up to 2 mg 2–3 times daily for severe symptoms
5. Major agitation in antipsychotic-naive patients: haloperidol PO 5 mg + promethazine PO 25 mg, repeat after 60 minutes; use IM route for hostile/aggressive behaviour
6. Long-acting haloperidol decanoate IM every 3–4 weeks: 25 mg monthly for patients on 2.5 mg daily PO, 50 mg for 5 mg daily, 100 mg for 10 mg daily, 150 mg for 15 mg daily
7. Treatment duration: at least one year, possibly lifelong for schizophrenia; uncertainty about follow-up is not a reason to withhold treatment
8. In older patients, reduce all antipsychotic doses by half regardless of medication used

Haloperidol decanoate IM dosing based on oral haloperidol dose

Table extracted from the guideline

Source: Médecins Sans Frontières, Chronic psychoses — MSF Clinical guidelines. Reproduced in summary form.

From the guideline

Verbatim

“Treatment should last at least one year, possibly for life, particularly in patients with schizophrenia. Uncertainty about the possibility of follow-up at one year or beyond is no reason not to treat.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

Related on GMJ

Interconnected resources

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