Medications for Schizophrenia

• Newer medications
• Side effects
• The National Institute for Clinical Excellence (NICE)
• Popular misconceptions about medication
• The effect of discontinuing treatment
• Relapse

Older medications

The first effective drugs for the treatment of schizophrenia were developed in the mid-1950s. There are a number of different 'conventional' antipsychotic drugs, such as haloperidol, chlorpromazine, fluphenazine, droperidol, pimozide, sulpiride, and thioridazine. These drugs seem to work mainly by reducing the effects of the neurotransmitter dopamine in the brain. They are mainly beneficial for treating the positive symptoms of schizophrenia, and enable many patients to remain out of hospital and to function well in the community. However, they do not seem to be very effective against the negative symptoms of schizophrenia, or mood symptoms (affective symptoms). The older medicines are available as tablets, liquids and short and long acting injections.

Newer medications

A number of newer, effective medications for schizophrenia have been introduced in the past decade or so. The newer antipsychotic drugs, such as aripiprazole, clozapine, olanzapine, quetiapine and risperidone, also known as atypical antipsychotics, appear to affect both the neurotransmitters serotonin and dopamine, and as a result they seem to have effects on a broader range of symptoms. They are effective in the treatment of psychosis, including hallucinations and delusions, and may also be helpful for treating the negative symptoms of the illness, such as reduced motivation, or flattened emotions. The newer medicines are also available as tablets and liquids and short and long acting injections.

Side effects

Antipsychotic drugs, like virtually all medications, can have unwanted effects along with their beneficial effects.

The older medicines are particularly associated with unpleasant movement problems, called extra-pyramidal symptoms (EPS), such as muscle spasms and stiffness, shaking and fidgeting. Patients may have to take additional medicines to combat these movement disorders. The long term side effects may be more of a problem, particularly tardive dyskinesia (TD). TD is involuntary movements mainly of the mouth and face, which are often irreversible.

The risk of these side effects with the newer medicines is much lower, but not totally absent. There is less likelihood of getting movement disorders and TD with the newer antipsychotics. However, some of the newer treatments are more likely to make people put on weight or have difficulty with sexual arousal.

Side effects may contribute to patients not taking their medication, which can lead to a relapse of schizophrenia symptoms and this is why it is important for people to discuss their treatment and any worrying side effects with their doctor.

NICE

The National Institute for Clinical Excellence (NICE) produced guidelines on the treatment and management of schizophrenia in December 2002* which includes guidance on the use of the newer (atypical) antipsychotic drugs.

NICE recommendations for patients state:

• That doctors should explain the benefits and side effects of drugs with patients and that the choice of antipsychotic should be made jointly.
• People who are newly diagnosed with schizophrenia should be offered one of the newer atypical antipsychotics.
• People experiencing side effects with older antipsychotics should be offered an atypical antipsychotic.
• People whose symptoms are controlled with older antipsychotics and are not experiencing troublesome side effects, should not have their treatment changed.

A copy of the NICE 'Information for Patients' can be obtained from the NHS Response Line: 0870 1555 455 and quoting the reference: N0106.

A large number of people with schizophrenia show substantial improvement when treated with antipsychotic drugs. Some patients, however, are not helped very much by the medications and a tiny proportion of people with schizophrenia do not seem to need them. It is difficult to predict which patients will fall into these two groups and to distinguish them from the large majority of patients who do benefit from treatment with antipsychotic drugs.

Popular misconceptions about medication

Patients and families sometimes become worried about the antipsychotic drugs used to treat schizophrenia. In addition to concern about side effects, they may worry that such drugs could lead to addiction. However, antipsychotic medications do not produce a 'high' (euphoria) or addictive behaviour in people who take them.

Another misconception about antipsychotic drugs is that they act as a kind of mind control, or a 'chemical straitjacket'. If used at the appropriate dose, antipsychotic drugs do not 'knock out' people or take away their free will. While some of these drugs can be sedating, this effect can be useful when treatment is started, especially if an individual is quite agitated. The usefulness of the drugs is not due to sedation but to their ability to reduce the hallucinations, agitation, confusion, and delusions of a psychotic episode. In this way, antipsychotic drugs should eventually help an individual with schizophrenia to deal with the world more appropriately.

The effect of discontinuing treatment

Antipsychotic drugs reduce the risk of future illness in patients who have recovered from an acute episode. Even with continued treatment, some people who have recovered will then relapse and become unwell again. Far higher relapse rates are seen when medication is discontinued. The treatment of severe psychotic symptoms generally requires higher dosages than those used for maintenance treatment. If symptoms reappear on a lower dose, a temporary increase in dose may prevent a full-blown relapse.

Relapse

Because relapse is more likely when antipsychotic medications are discontinued or taken irregularly, it is very important that people with schizophrenia agree a treatment and relapse plan with their doctors and family that suits them.

It is essential then to find support for the individual so that they can adhere to the agreed plan. This involves taking the prescribed medication at the correct dose and proper times each day, attending clinic appointments, and carefully following other treatment procedures. While this is often difficult, there are strategies and therapies that can greatly improve the outcome and often lead to a better quality of life.

During a relapse people can become withdrawn, have heightened senses and find that those around them are incapable of understanding what is going on. The person's ability to distinguish between their idea of reality and other peoples might also reduce.

Quite often people know when they are becoming ill again - but are not always able to do anything about it. Many people have a "relapse signature" and if this can be identified this can help to reduce both the severity and duration of the relapse. A relapse signature is nothing more than a fancy way of saying 'warning signs' and friends and relatives can often help in spotting them early.

Some examples of these signs might be sleeping less, eating less, not getting up or not being able to concentrate as well as usual. If these symptoms can be dealt with early it is quite likely that the person will improve more quickly and be able to get on with their life.

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