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Medical Author:

Roxanne Dryden-Edwards, MD

Roxanne Dryden-Edwards, MD

Dr. Roxanne Dryden-Edwards is an adult, child, and adolescent psychiatrist. She is a former Chair of the Committee on Developmental Disabilities for the American Psychiatric Association, Assistant Professor of Psychiatry at Johns Hopkins Hospital in Baltimore, Maryland, and Medical Director of the National Center for Children and Families in Bethesda, Maryland.

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Medical Editor:

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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Antipsychotics have been proven effective in treating acute psychosis and reducing the risk of future psychotic episodes. The treatment of schizophrenia thus has two main phases: an acute phase, when higher doses of medication might be necessary in order to treat psychotic symptoms, followed by a maintenance phase, which could be lifelong. During the maintenance phase, the medication dosage is gradually reduced to the minimum required to prevent further episodes. If symptoms reappear on a lower dosage, a temporary increase in dosage may help prevent a relapse.

Even with continued treatment, some patients experience relapses. By far, though, the highest relapse rates are seen when medication is discontinued.

The large majority of patients experience substantial improvement when treated with antipsychotic agents. Some patients, however, do not respond to medications, and a few may seem not to need them.

Since it is difficult to predict which patients will fall into what groups, it is essential to have long-term follow-up, so that the treatment can be adjusted and any problems addressed promptly.

Antipsychotic medications are the cornerstone in the management of schizophrenia. They have been available since the mid-1950s, and although antipsychotics do not cure the illness, they greatly reduce the symptoms and allow the patient to function better, have a better quality of life, and enjoy an improved outlook. The choice and dosage of medication is individualized and is best done by a physician who is well trained and experienced in treating severe mental illness.

The first antipsychotic was discovered by accident and then used for schizophrenia. This was chlorpromazine (Thorazine), which was soon followed by medications such as haloperidol (Haldol), fluphenazine (Prolixin), thiothixene (Navane), trifluoperazine (Stelazine), perphenazine (Trilafon), and thioridazine (Mellaril). These medications have become known as "neuroleptics" because, although effective in treating positive symptoms (for example, acute symptoms such as hallucinations, delusions, thought disorder, loose associations, ambivalence, or emotional lability), they cause side effects, many of which affect the neurologic (nervous) system. These older medications are thought to be not as effective against symptoms such as decreased motivation and lack of emotional expressiveness.

Since 1989, a new class of antipsychotics (atypical antipsychotics) has been introduced. At clinically effective doses, none (or very few) of these neurological side effects, which often affect the extrapyramidal nerve tracts (which control such things as muscular rigidity, painful spasms, restlessness, or tremors) are observed.

The first of the new class, clozapine (Clozaril), is the only agent that has been shown to be effective where other antipsychotics have failed. Its use is not associated with extrapyramidal side effects, but it does produce other side effects, including a possible decrease in the number of white blood cells, so the blood needs to be monitored every week during the first six months of treatment and then every two weeks to catch this side effect early if it occurs.

Other atypical antipsychotics include risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), paliperidone (Invega), asenapine (Saphris), and iloperidone (Fanapt). The use of these medications has allowed successful treatment and release back to their homes and the community for many people suffering from schizophrenia.

Although more effective and better tolerated, the use of these agents is also associated with side effects, and current medical practice is developing better ways of understanding these effects, identifying people at risk, and monitoring for the emergence of complications.

Most of these medications take two to four weeks to take effect. Patience is required if the dose needs to be adjusted, the specific medication changed, and another medication added. In order to be able to determine whether an antipsychotic is effective or not, it should be tried for at least six to eight weeks (or even longer with clozapine).

Since people with schizophrenia are at increased risk of also developing depression, medications that address that symptom may be of great benefit as well. Serotonergic medications like fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro) are often prescribed because of their effectiveness and low incidence of side effects. Other often prescribed antidepressant medications for schizophrenia include venlafaxine (Effexor), duloxetine (Cymbalta), and buproprion (Wellbutrin).

Because the risk of relapse of illness is higher when antipsychotic medications are taken irregularly or discontinued, it is important that people with schizophrenia follow a treatment plan developed in collaboration with their doctors and with their families. The treatment plan will involve taking the prescribed medication in the correct amount and at the times recommended, attending follow-up appointments, and following other treatment recommendations.

People with schizophrenia often do not believe that they are ill or that they need treatment. Other possible things that may interfere with the treatment plan include side effects from medications, substance abuse, negative attitudes toward treatment from families and friends, or even unrealistic expectations. When present, these issues need to be acknowledged and addressed for the treatment to be successful.

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