Schizophrenia
Treatment The effectiveness of treatment is determined by how fast the
patient presents to the care of the psychiatrist or physician. At present
this delay from the first psychotic symptoms to the start of treatment with antipsychotic
medications is about 12 to 24 months! Without prophylactic antipsychotic medication
the relapse rate(meaning a renewed bout of schizophrenia) is 75% within 1 year
from the first episode. With antipsychotic medication prophylaxis this rate goes
down to about 30%. However, with every relapse of schizophrenia a little mental
scar remains and the brain metabolism deranges more and more. We do not have all
the answers about schizophrenia. We also do not have the ideal medication with
only a good, stabilizing effect and no side-effect. But it is better to be able
to offer something than nothing. We have the conventional antipsychotic medications(
also called "neuroleptic medications") and the atypical antipsychotic
medications. In the following I will briefly review the more common medications.
| Conventional
antipsychotic medication: | | Pharmacological
name: | Brand
name: | | Chlorpromazine
| Largactil, Ormazine,
Thorazine | | Haloperidol
| Haldol |
| Mesoridazine | Serentil |
Thioridazine | Mellaril |
| Trifluoperazine | Stelazine |
| Loxapine | Loxapac,
Loxitane | Perphenazine | Trilafon |
| Molindone | Moban |
| Thiothixene | Navane |
| Pimozide | Orap |
Side effects of conventional medication:
These
medications are not without problems. One of the unpleasant side-effects is motor
restlessness(="akathisia"), which often leads
to terminating therapy by the patient. Another more severe side-effect
is tardive dyskinesia, which occurs in 5% per year of
antipsychotic medication use and in about 1%-2% of these it is severely disfiguring
the face. Tardive dyskinesia can lead to permanent involuntary movements of the
muscles around the moth and the eyes. The jaw and the tongue may also show involuntary
movements and in time this leads to a disfigured look of the face, often with
asymmetries between right and left. Unfortunately, withdrawal of the antipsychotic
medications will often not improve the tardive dyskinesia. Often expensive lifelong
Botox injection therapy every 6 to 8 weeks is required to alleviate some of the
effects of this devastating dyskinesia. A more rare, but very dangerous
side-effect is the neuroleptic malignant syndrome. It
happens in about 3% of patients that were started on antipsychotic medications,
usually right in the beginning of starting therapy. It likely is caused by the
blocking of central dopamine receptors. Symptoms consist of muscle rigidity, a
high fever, fast heart beat, high blood pressure, rapid breathing and a change
of consciousness. It is a severe syndrome of autonomic dysfunction. The blood
tests are very abnormal with a severe acidosis, elevated CK enzyme levels( a muscle
enzyme), myoglobinuria and others. This syndrome has a high mortality rate
of about 25% to 30%. Treatment for this requires admission to an Intensive Care
Unit in a hospital. The antipsychotic medication is withheld. Dopamine agonist
therapy with bromocriptine (brand name: Parlodel) is used in combination with
supportive measures. Other side-effects are common such as extrapyramidal
side-effects that mimic Parkinson disease. Symptoms can include
trembling of the hands, shakiness of the upper extremity muscles as well as muscle
rigidity, cogwheel phenomenon when testing muscle mobility and balancing problems.
Benztropine (brand name: Cogentin) is helpful in treating this.
| Atypical antipsychotic
medication: | | Pharmacological
name: | Brand
name: | | Risperidone | Risperdal |
| Clozapine | Clozaril |
| Olanzapine | Zyprexa |
| Quetiapine | Seroquel |
These newer atypical antipsychotic medications
against schizophrenia have a lesser risk of tardive dyskinesia. They work in about
50% of cases where the conventional antipsychotic medications failed. They produce
less extrapyramidal Parkinson disease like symptoms. However, they have
again their unique side-effects. Clozapine, for example, leads to agranulocytosis
in 1% of cases. This is a serious side-effect where the stem cells of the bone
marrow get poisoned and the patient dies of serious infections against which nothing
can be done. On the other hand in 99% of the cases Clozapine can do wonders in
stabilizing a schizophrenia, which could not be stabilized before with the conventional
medicines.
Other Supportive Measures There is a network of
support services in many communities, which is very useful in helping patients
maintain their independence at home for as long as possible. Patients do much
worse, if they do not interact with others. Part of such support services are
also regular mild exercise classes or such activities as walking clubs or swimming
groups. When the chronic schizophrenic patient has problems coping in the
regular job world many communities have now sheltered job situations that are
supervised by staff who have experience with patients with schizophrenia. Self-help
groups exist and are growing in number. More needs to be done, but there are limits
of government agencies and volunteers. However, when the safety net fails, the
"alternative" for the chronic schizophrenic is to join the street people
or to end up in one of the homes. Many become disparate, depressed and
suicidal. The physician may have to add an antidepressant medication to the other
medication. At times the psychiatrist may decide to give a treatment course of
electroconvulsive therapy, which has a good response rate and avoids the accumulation
of side-effects. Although family support is excellent and helpful, often family
members are afraid and hurt from what happened in the past before treatment was
instituted, and they may want to avoid a closer contact. Schizophrenia
is one of the major psychiatric illnesses and more research is needed. It likely
will be some time before more effective, less invasive therapy will be introduced.
Some hope may come from the eicosanoid research( essential fatty acid metabolism
research) as the brain is made up of about 1/6-th of its mass as polyunsaturated
fatty acids with the highest concentration of ecosanoids in the body. Here
is a link regarding further reading about
treatment of schizophrenia. |
