Antipsychotic medications are the mainstay of treatment. Mainly the medicines can be classified into two groups, 1st generation antipsychotics and second generation antipsychotics.
1st generation antipsychotics include the older antipsychotics i.e Haloperidol, chlorpromazine, trifluoperazine, pimozide, zuclopenthixol etc, while the
2nd generation antipsychotics include olanzapine, risperidone, quetiapine, clozapine, aripiprazole, amisulpride etc and newer antipsychotics like caripraszine, asenapine, blonanserine.
The two classes have minimal differences in terms of efficacy and adherence to treatment (except clozapine which is more efficacious than any other antipsychotic). So, the choice of drug depends on past response, affordability, psychiatric and medical comorbidities, side effects, patient/family preference, route of administration, compliance.
General principle of staying antipsychotics is ‘Start Low, Go Slow’ i.e the medications should be started at lowest possible dose and titrated up slowly. The patient should be maintained on lowest possible dose and with minimum possible number of medication (poly pharmacy is usually avoided).
Preferred route of administration is oral tablets but in case the patient prefers or rapid control of behavioral disturbance is required or the patient is uncooperative injectable medications may be used. Both short acting and long acting injections are available.
Long acting injectables are usually used to ensure compliance and a test dose is administered during starting of treatment.
Usually first generation antipsychotics have more extrapyramidal symptoms (especially high potency antipsychotics) which increases the risk of non-compliance while the second generation medications have more metabolic side effects (including weight gain, diabetes, dyslipidemia, hypertension, metabolic syndrome). Other common side effects can be sedation, dry mouth, blurred vision, constipation, postural hypotention. Generally, 2nd generation antipsychotics are preferred in drug naive patients.
Management of acute psychotic episode
An adequate trial is considered when an antipsychotic is taken for at least 6-8 weeks (except clozapine, at least 6 months) at therapeutic dose with good compliance.
In case the patient responds to given medications the same is continued.
In case there is minimal or no response 2nd antipsychotic is tried at adequate dose and duration.
Failure to respond to 2 antipsychotics is considered treatment resistant schizophrenia, around 20-30% of the patients have treatment resistant schizophrenia. Clozapine is considered in such patients for treatment with periodic monitoring for side effects including regular monitoring of CBC (mainly TLC and ANC), as 1% of the patients have risk of developing agranulocytosis. One of the major benefits of using clozapine is that it has anti-suicidal effect.
Long term maintenance treatment:
Maintenance treatment is required for control over symptoms, reducing risk of relapse, improve quality of life.
The patient may require to take the medications for 1-2 years (in first episode) to lifelong (in multiple/severe episodes).
All throughout the treatment the patient is assessed for improvement and side effects and the dose of medicine is adjusted accordingly. In case patient maintains on treatment for 2 continuous years the dose of medications may be reduced very gradually with regular monitoring for early signs of relapse.
During the initial phase of treatment follow ups are frequent (once or twice a month) and eventually during maintenance phase they can be spaced between once in 2-3 months and more frequent in time of crisis.
ECT has proved to be a effective treatment modality especially during acute phase of illness where it is used for augmentation and quick response although the positive response lasts only a few weeks. Mostly it is used in case of catatonic symptoms, need for rapid control of symptoms, suicidal behaviour, severe agitation or violence, resistant schizophrenia.
Antipsychotics are the mainstay of treatment but other drugs including mood stabilizers, benzodiazepines, and antidepressants may be used as an adjective treatment.
Like lithium in used in agitated, overactive patient, benzodiazepines for controlling acute agitation and sleep disturbance.