Medications for Schizophrenia and Psychosis

By 25 Nov 2000

A person who is psychotic is out of touch with reality. He may "hear voices" or have strange and untrue ideas (for example, thinking that others can hear his thoughts, or are trying to harm him, or that he is the President of the United States or some other famous person).

He may get excited or angry for no apparent reason, or spend a lot of time off by himself, or in bed, sleeping during the day and staying awake at night. He may neglect his appearance, not bathing or changing clothes, and may become difficult to communicate with saying things that make no sense, or barely talking at all.

These kinds of behaviors are symptoms of psychotic illness, the principal form of which is schizophrenia. All of the symptoms may not be present when someone is psychotic, but some of them always are.

Antipsychotic medications, as their name suggests, act against these symptoms. These medications cannot "cure" the illness, but they can take away many of the symptoms or make them milder. In some cases, they can shorten the course of the illness as well.

There are a number of antipsychotic (neuroleptic) medications available. They all work; the main differences are in the potency that is, the dosage (amount) prescribed to produce therapeutic effects and the side effects. Some people might think that the higher the dose of medication, the more serious the illness, but this is not always true.

A doctor will consider several factors when prescribing an antipsychotic medication, besides how "ill" someone is. These include the patient's age, body weight and type of medication.

Past history is important, too. If a person took a particular medication before and it worked, the doctor is likely to prescribe the same one again. Some less potent drugs, like chlorpromazine (Thorazine), are prescribed in higher numbers of milligrams than others of high potency, like haloperidol (Haldol).

If a person has to take a large amount of a "high-dose" antipsychotic medication, such as chlorpromazine, to get the same effect as a small amount of a "low-dose" medication, such as haloperidol, why doesn't the doctor just prescribe "low-dose" medications?

The main reason is the difference in their side effects (actions of the medication other than the one intended for the illness). These medications vary in their side effects, and some people have more trouble with certain side effects than others. A side effect may sometimes be desirable. For instance, the sedative effect of some antipsychotic medications is useful for patients who have trouble sleeping or who become agitated during the day.

Unlike some prescription drugs, which must be taken several times during the day, antipsychotic medications can usually be taken just once a day. Thus, patients can reduce daytime side effects by taking the medications once, before bed. Some antipsychotic medications are available in forms that can be injected once or twice a month, thus assuring that the medicine is being taken reliably.

Most side effects of antipsychotic medications are mild. Many common ones disappear after the first few weeks of treatment. These include drowsiness, rapid heartbeat, and dizziness when changing position.

Some people gain weight while taking antipsychotic medications and may have to change their diet to control their weight. Other side effects that may be caused by some antipsychotic medications include decrease in sexual ability or interest, problems with menstrual periods, sunburn, or skin rashes.

If a side effect is especially troublesome, it should be discussed with the doctor who may prescribe a different medication, change the dosage level or schedule, or prescribe an additional medication to control the side effects.

Movement difficulties may occur with the use of antipsychotic medications, although most of them can be controlled with an anticholinergic medication. These movement problems include muscle spasms of the neck, eye, back, or other muscles; restlessness and pacing; a general slowing-down of movement and speech; and a shuffling walk. Some of these side effects may look like psychotic or neurologic (Parkinson's disease) symptoms, but aren't.

If they are severe, or persist with continued treatment with an antipsychotic, it is important to notify the doctor, who might either change the medication or prescribe an additional one to control the side effects.

Just as people vary in their responses to antipsychotic medications, they also vary in their speed of improvement. Some symptoms diminish in days, while others take weeks or months. For many patients, substantial improvement is seen by the sixth week of treatment, although this is not true in every case. If someone does not seem to be improving, a different type of medication may be tried.

Even if a person is feeling better or completely well, he should not just stop taking the medication. Continuing to see the doctor while tapering off medication is important. Some people may need to take medication for an extended period of time, or even indefinitely.

These people usually have chronic (long-term, continuous) schizophrenic disorders, or have a history of repeated schizophrenic episodes, and are likely to become ill again. Also, in some cases a person who has experienced one or two severe episodes may need medication indefinitely. In these cases, medication may be continued in as low a dosage as possible to maintain control of symptoms. This approach, called maintenance treatment, prevents relapse in many people and removes or reduces symptoms for others.

While maintenance treatment is helpful for many people, a drawback for some is the possibility of developing long-term side effects, particularly a condition called tardive dyskinesia. This condition is characterized by involuntary movements. These abnormal movements most often occur around the mouth, but are sometimes seen in other muscle areas such as the trunk, pelvis, or diaphragm.

The disorder may range from mild to severe. For some people, it cannot be reversed, while others recover partially or completely. Tardive dyskinesia is seen most often after long-term treatment with antipsychotic medications. There is a higher incidence in women, with the risk rising with age. There is no way to determine whether someone will develop this condition, and if it develops, whether the patient will recover.

At present, there is no effective treatment for tardive dyskinesia. The possible risks of long-term treatment with antipsychotic medications must be weighed against the benefits in each individual case by patient, family, and doctor.

Antipsychotic medications can produce unwanted effects when taken in combination with other medications. Therefore, the doctor should be told about all medicine being taken, including over-the-counter preparations, and the extent of the use of alcohol.

Some antipsychotic medications interfere with the action of antihypertensive medications (taken for high blood pressure), anticonvulsants (taken for epilepsy), and medications used for Parkinson's disease. Some antipsychotic medications add to the effects of alcohol and other central nervous system depressants, such as antihistamines, antidepressants, barbiturates, some sleeping and pain medications, and narcotics.

Atypical Neuroleptics
In 1990, clozapine (Clozaril), an "atypical neuroleptic," was introduced in the United States. In clinical trials, this medication was found to be more effective than traditional antipsychotic medications in individuals with treatment-resistant schizophrenia, and the risk of tardive dyskinesia is lower.

However, because of the potential side effect of a serious blood disorder, agranulocytosis, patients who are on clozapine must have a blood test each week. The expense involved in this monitoring, together with the cost of the medication, has made maintenance on clozapine difficult for many persons with schizophrenia.

However, five years after its introduction in the United States, approximately 58,000 people were being treated with clozapine.

Since clozapine's approval in the United States, other atypical neuroleptics (also called atypical antipsychotics) have been introduced. Risperidone (Risperdal) was released in 1994, olanzapine (Zyprexa) in 1996, and quetiapine (Seroquel) in 1997. Several other atypical neuroleptics are in development.

While they have some side effects, these newer medications are generally better tolerated than either clozapine or the the traditional antipsychotics, and they do not cause agranulocytosis. Like clozapine, they have shown little tendency to give rise to tardive dyskinesia or other movement difficulties. Their main disadvantages compared to the older medications are a greater tendency to produce weight gain, and much higher cost.

Last reviewed: By John M. Grohol, Psy.D. on 9 Oct 2013
    Published on PsychCentral.com. All rights reserved.

 

 

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