Medication

The medications used to treat schizophrenia, commonly referred to as 'antipsychotics', are generally an effective method for decreasing the psychotic (or active) symptoms of schizophrenia, such as delusions and hallucinations. The newer antipsychotics can also help relieve some of the passive symptoms (such as confusion, withdrawal, suicidal thoughts and lack of concentration). For many people with schizophrenia, medication will also be needed during stable phases (also called 'maintenance' or 'recovery' phases). While it can sometimes be a temptation to stop taking medication, especially during the recovery phase or when side effects are distressing, it is important to understand the real risks involved in doing so. Studies have concluded that four out of five people who stop taking their medications after a first episode of schizophrenia will relapse2. Any decisions, therefore, to stop, change or alter the dosage of your medication should always involve your doctor.

Determining the type and dosage of medication needs to be individually assessed for each person and may need to be altered until the right combination is achieved. A general rule of thumb is to find the lowest possible dose of medication that effectively reduces the symptoms and prevents relapse. If you or a family member are being treated with medication, make sure you ask:

• What the desired effects of the medication are
  
• Why it is needed
  
• How and when it is taken
  
• What side effects the medication can cause
  
• What special warnings or restrictions apply to the use of the medication.

Remember - although medication is almost always necessary, it should not be considered the sole treatment for schizophrenia. Rather, it should be used in addition to other therapies described later in this section.

Types of medications
Typical antipsychotic medications3
Typical antipsychotics (also called 'conventional' antipsychotics) have been used for the treatment of schizophrenia since the 1950s. They are available in tablet form, long-lasting injections (called 'depot') and also as fast intramuscular preparations. These older medications are highly effective in the treatment of active symptoms in 60-70% of people. However, they are less effective on passive symptoms and are often associated with unpleasant side effects.

Atypical antipsychotic medications4
The emergence of atypical antipsychotic medications has offered great hope for improving the treatment of schizophrenia. Atypical medications appear superior to typical medications in treating the passive symptoms of schizophrenia and they appear to cause fewer extra-pyramidal side effects (involuntary movements such as tremors, muscle spasm or uncontrollable restlessness).

Clozaril5
Clozaril, introduced in 1990, was the first atypical antipsychotic and can be helpful for 25%-50% of people who have not responded to other atypical antipsychotics. However, Clozaril has a rare but potentially very serious side effect. In less than 1% of those taking Clozaril, it can decrease the number of white blood cells necessary to fight infection, a condition that is called 'agranulocytosis'. This means that people receiving Clozaril must have their blood checked regularly. It is generally recommended that Clozaril be used only after at least two other safer antipsychotics have not worked.

Selecting medication
The increasing trend is to recommend the newer (atypical) antipsychotics as the pharmaceutical treatment of choice for someone experiencing their first episode of schizophrenia. If a person has a relapse because of not taking the medication as prescribed, the dosage may be lowered, a medication to control side effects added, or a switch to a medication with fewer side-effects may be recommended (usually an atypical antipsychotic). Alternatively, switching to a long-acting injection given every 2-4 weeks may be suggested. Sometimes a person may relapse despite taking the medication as prescribed, which is generally considered a good reason to switch to another medication - usually a newer antipsychotic if the person was taking a conventional (older) antipsychotic, or a different newer antipsychotic if the person had already tried an atypical antipsychotic. Fortunately, even if someone has not responded well to a number of other antipsychotics, Clozapine is available as a backup and may work when other things have failed.

How long does it take to work?
Antipsychotics usually take a while before they begin working and can take anywhere up to six weeks before there is any noticeable effect (with the exception of Clozapine, which can take up to twelve weeks), although you may start to notice an effect within two weeks.

What are the possible side effects of antipsychotics?
Because most people with schizophrenia have to take medication for a long period of time, it is important to avoid and manage unpleasant side effects. One of the biggest problems with typical antipsychotics is that they often cause muscle movements or rigidity called extrapyramidal side effects. Sometimes, medications will be prescribed in addition to antipsychotics to prevent or treat these particular side effects. Other potential problems can include sedation, weight gain and effects in sexual functioning. A list of some of the possible side effects is given below.

Remember - medication affects people in different ways. You may or may not experience some of the side effects listed below. Some side effects, although very rare, have the potential to be life threatening, so if you do develop side effects, let your doctor know straight away. Your doctor may do a number of things to help manage side effects, including6:

• Waiting a while to see whether the side effects disappears on its own
  
• Reducing the dosage of medicine
  
• Trying another medicine
  
• Adding another medication to treat the side effect
  

Much evidence shows that schizophrenia is accompanied by changes in the structure and function of the brain, influenced often by psychological and social stress. Medication, supplemented by psychological and social rehabilitation, is the basis of treatment.

The medications used are major tranquillisers (also known as neuroleptics and antipsychotic drugs). They reduce the effects of over-active neurotransmitters in the brain, especially dopamine, and help the client to settle down and see things more rationally. Some of the newer medications, and others in development, act on other neurotransmitters, such as serotonin.

Different people vary widely in their response to medications and in their susceptibility to side-effects. All doses should be individualised, taking into consideration: age, body weight, physical state, ethnic background, underlying pathological condition, and the use of other drugs.

Many people with a diagnosis of schizophrenia need to take medication for extended periods. It seems that once life stressors have been minimised and some routine lifestyle achieved, less medication is needed.

Frequently people with schizophrenia decide to stop taking their medication ("I'm cured now. If I need it again, I'll go back on medication!"). Unfortunately, by the time they need medication, it often happens that they are not able to appreciate this and another breakdown is highly likely. However, some people do learn how to monitor their need for medication.

People taking any of the medications should avoid the use of illegal or street drugs as they may cause their mental state to deteriorate.

Alcohol may be consumed in very moderate amounts, e.g. one can of beer, preferably a low-alcohol brand, or one glass of wine. However, if consumed in large amounts, alcohol will promote the return of psychotic symptoms.

Medications

Some common medications and their usual daily dose ranges are listed below. However, doses above the usual range are sometimes required, but doses below the usual range are preferred. Assume tablet form, unless IMI (intra-muscular injection) is indicated.

• Chlorpromazine (Largactil™) 75-800 mg, also available as IMI
• Pericyazine (Neulactil™) 15-30 mg
• Thioridazine (Melleril™, Aldazine™) 50-600 mg
• Pimozide (Orap™) 4-10 mg
• Fluphenazine decanoate (Modecate™) 12.5-25 mg IMI every 1-4 wk
• Trifluoperazine (Stelazine TM, Calmazine™) 2-30 mg
• Flupenthixol decanoate (Fluanxol™) 20-100 mg IMI every 2-4 weeks
• Thiothixene (Navane™) 6-30 mg
• Haloperidol decanoate (Haldol™) 25-300 mg IMI every 2-4 weeks
• Haloperidol (Serenace™) 2-10 mg also available as IMI or drops
• Clozapine (Clozaril™, Clopine™) 12.5-600 mg
• Risperidone (Risperdal™) 2-8 mg
• Olanzapine (Zyprexa™) 5-20 mg
• Zuclopenthixol (Clopixol™) 10-15 mg
• Zuclopenthixol decanoate (Clopixol™ depot) 200-400 ml IMI every 2-4 weeks
• Quetiapine (Seroquel™) 200-800 mg
• Amulsulperide (Solian™) 100-1200 mg

What are the side effects?

All medications have side-effects and the skill of prescribing is to achieve a balance between desirable and unwanted effects. Individuals vary markedly in their responses to different medications. Some of the common side-effects are:

Drowsiness: is the most common side-effect. People who are drowsy shouldn't work machinery or drive.

Dry mouth: for which we suggest people use sugarless gum to stimulate the production of saliva.

Weight gain and/or constipation: People with these problems should have a sensible, high-fibre diet and fluids combined with exercise. Body weight should be monitored. A program should be put in place to combat expected gains on some medications, such as olanzapine and clozapine.

Lowering of blood pressure: This can be experienced as dizziness or faintness. Affected people should rise slowly from a sitting or lying position and sit on the side of the bed before standing up. If symptoms persist, a medication review is necessary.

Menstrual disorders: or false positive pregnancy tests. If these side-effects persist over a period of weeks, the client should return to the prescriber for a medication review. To stop medication without supervision may lead to deterioration in the person’s mental state. It is very important for people on long-term medication to have regular reviews. An underlying principle is that medication should be the minimum necessary to prevent relapse as well as minimising the risk of side-effects. This may only be achieved on a trial and error basis. Another group is called extra-pyramidal side-effects. These affect certain muscles of the body and can lead to discomfort for the client.

Dystonias: Eyes turning upwards, a distressing situation for the client who may need immediate medical intervention; slurred speech; large muscle contractions leading to odd posture or even arching of the back.

Parkinsonian features: tremor, muscular rigidity or absence of normal movement.

Akathisia: a feeling of generalised restlessness, often worse in the legs. People feel unable to sit still, they must get up and move about. They feel worried and uncomfortable.

Tardive dyskinesia: This involves an abnormal chewing of the lips and tongue, sometimes movement of fingers and toes, and occasionally also trunk muscles. This may be mild and barely noticeable. Of all the side-effects, it is the only one that is irreversible if not treated early.

Agranulocytosis: Clozapine has a rare but fatal potential to depress the body's white cells (which fight infection). Regular blood tests are needed to monitor the white cell count.

Cardiac or heart problems: Many medications, but especially thioridazine and clozapine, have caused potentially fatal heart problems, ranging from changes in rhythm to inflammation. Heart health should therefore be monitored in people on these medications, or in anyone with existing heart problems.

Neuroleptic Malignant Syndrome (NMS): A rare but potentially fatal syndrome that can develop at any time. It is mostly seen in hospitals when acutely excited individuals have been given large or rapidly escalating doses. The major features of NMS are: fever, muscular rigidity, high and fluctuating blood pressure and pulse and respiratory rates. Side-effects can be relieved by reducing or increasing medication, or by adding different medications. Dystonias, Parkinsonian features and akathisia can be treated with anticholinergics such as benztropine mesylate (Cogentin™), benzhexol (Artane™), procyclidine hydrochloride (Kemadrin™) and orphenadrine (Disipal™). Side-effects may be uncomfortable, but they often improve with time and dose reduction. Stopping the medication "cold turkey" is not the answer. We strongly recommend an immediate visit to the prescribing doctor.

Diabetes: Some recent research suggests that there may be a link between atypical medications and an increased rate of diabetes. There is not an established causal link. People taking atypical medications should discuss this issue with their treating doctor and learn about the warning signs of diabetes so that if it is developing it can be detected quickly and managed.