Psychosis
Schizoaffective disorder: what it is, symptoms and treatment
Psychosis together with mania or depression: what schizoaffective disorder is, how it differs from schizophrenia and bipolar disorder, and how it is treated.
Schizoaffective disorder is a long-term mental illness in which symptoms of psychosis, such as hallucinations or delusions, occur together with episodes of mania or depression. It sits between schizophrenia and bipolar disorder, and it is one of the most difficult diagnoses in psychiatry. It can be treated, usually with a combination of medication, psychotherapy and regular follow-up.
What exactly is it?
The American diagnostic manual, DSM-5, requires all of the following:
during one continuous period of illness, a major episode of mania or depression occurs together with the symptoms of schizophrenia; if it is depression, low mood must be present
there is a period of at least 2 weeks with hallucinations or delusions without a mood episode
mood symptoms are present for most of the total duration of the illness
the symptoms are not caused by a substance, a medicine or another medical condition
There are two types. In the bipolar type there are episodes of mania and sometimes also of depression. In the depressive type there are only episodes of depression.
Schizophrenia, bipolar disorder or schizoaffective disorder?
The difference is judged mainly by timing:
Bipolar disorder or depression with psychotic features: psychosis appears only within the mood episodes.
Schizoaffective disorder: psychosis continues for at least 2 weeks without a mood episode, while mood episodes cover most of the illness.
Schizophrenia: mood episodes, if any, cover a small part of the total duration.
That is why the diagnosis is often not made at the first visit. In an analysis of 31 studies that re-examined the same patients (usually two years later), 36% of those first diagnosed with schizoaffective disorder later received another diagnosis: 19% schizophrenia, 14% a mood disorder and 6% another disorder. The researchers recommend reassessing the diagnosis during the course of the illness and adjusting treatment.
I treat the diagnosis as a working hypothesis that is reviewed, not as a label for life. In the assessment I also ask for information from someone who knows you well, because the order of symptoms over time is clearer from two points of view.
How common is it?
In a survey of a representative sample of 8,028 adults aged 30 and over in Finland, 0.32% had had schizoaffective disorder at some point in their life, and 0.87% schizophrenia. The StatPearls database reports that it is more common in women and that it often begins in young adulthood. Large epidemiological studies are lacking, partly because the criteria have changed many times.
What are the symptoms?
Psychotic symptoms:
hallucinations, most often voices
delusions, for example that someone is watching or harming you
disorganised speech or behaviour
Mood symptoms:
in mania: greatly increased energy, very little need for sleep, rapid speech, impulsive decisions
in depression: low mood, loss of interest, fatigue, thoughts of hopelessness
A 2019 review notes that its course lies between that of schizophrenia and that of bipolar disorder, and that it appears to be highly heritable.
How is it treated?
Medication. The basis is antipsychotic medication. Depending on the type, mood stabilisers or antidepressants are added.
In a review of studies that included only patients with schizoaffective disorder, paliperidone (by mouth and as a long-acting injection) and risperidone were shown in controlled studies to reduce both psychotic and mood symptoms. Paliperidone also showed benefit in long-term relapse prevention. The authors note that such studies are few.
In a two-year randomised study of 980 patients with schizophrenia or schizoaffective disorder at high risk of suicide, clozapine reduced suicidal behaviour more than olanzapine.
Medication is changed or stopped only by the doctor who follows you, never by you alone. Stopping without a plan is a common cause of relapse.
Psychotherapy and psychoeducation. Individual psychotherapy, family interventions and psychoeducation help with everyday functioning and relapse prevention.
Electroconvulsive therapy. It is used in urgent or treatment-resistant cases.
From the start we agree an “if-then” plan: which signs show that a relapse is coming, what you and your family do, and when to call me. And when a treatment does not bring the result, I first check whether it was tried for long enough, before we change the whole plan. Often a targeted addition is enough.
What the family can do
Learn the early signs of relapse in your loved one: less sleep, withdrawal, suspiciousness, a marked change in mood.
Support the continuity of treatment, without pressure and without guilt.
Ask for support for yourself too.
When to ask for help
You hear voices or have beliefs that the people around you find strange.
Your mood changes sharply, with periods without sleep or with severe depression.
You already have a diagnosis and notice signs of relapse.
Your treatment is not helping or you have unpleasant side effects.
Safety: If there are thoughts of suicide or of harming someone, or if your loved one cannot look after themselves, call 166 (ambulance, EKAV) or 112 immediately. The Suicide Prevention Line 1018 is also available 24 hours a day.
How I can help
Book a psychiatric assessment, at the practice in Trikala or online. See the page on schizophrenia and psychosis and the article Psychosis and the first psychotic episode. Follow-up can also take place from your home: see how working with an online psychiatrist works, or book an appointment.
This article is educational and does not replace individual clinical assessment. Do not change or stop any treatment you are already taking without talking to your doctor.
Sources
Wy TJP, Saadabadi A. Schizoaffective Disorder. StatPearls, NCBI Bookshelf. Last updated 27 March 2023. Accessed 12 November 2026. https://www.ncbi.nlm.nih.gov/books/NBK541012/
Santelmann H, Franklin J, Bußhoff J, Baethge C. Diagnostic shift in patients diagnosed with schizoaffective disorder: a systematic review and meta-analysis of rediagnosis studies. Bipolar Disord. 2016. https://doi.org/10.1111/bdi.12388
Perälä J, et al. Lifetime prevalence of psychotic and bipolar I disorders in a general population. Arch Gen Psychiatry. 2007. https://doi.org/10.1001/archpsyc.64.1.19
Miller JN, Black DW. Schizoaffective disorder: A review. Ann Clin Psychiatry. 2019. https://pubmed.ncbi.nlm.nih.gov/30699217/
Lindenmayer JP, Kaur A. Antipsychotic Management of Schizoaffective Disorder: A Review. Drugs. 2016. https://doi.org/10.1007/s40265-016-0551-x
Meltzer HY, et al. Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Arch Gen Psychiatry. 2003. https://doi.org/10.1001/archpsyc.60.1.82
