What Medications Treat Schizophrenia?
Antipsychotics have been proven effective in treating acute psychosis as well as 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. Clinical research has shown that if relapses can be prevented, the long-term functioning and prognosis for the individual are better. Longer periods of untreated psychosis may also predict a poorer prognosis, further emphasizing the importance of remaining in treatment.
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 have a complete recovery and not need long-term medication.
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.
Antipsychotics are the cornerstone in the medication treatment 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, usually a psychiatrist, who is well trained and experienced in treating severe mental illness.
The first antipsychotic, chlorpromazine (Thorazine) was initially developed as an anti-histamine but was found in the 1950s to be effective for treating psychosis, including schizophrenia. It was later learned that its effectiveness was related to blocking dopamine activity in the brain. In the late 1950s and early 1960s, a number of other antipsychotics were developed, including haloperidol (Haldol), fluphenazine (Prolixin), thiothixene (Navane), trifluoperazine (Stelazine), perphenazine (Trilafon), and thioridazine (Mellaril). These medications have become known as first-generation antipsychotics and have been found to be effective in treating positive symptoms (for example, acute symptoms such as hallucinations, delusions, thought disorder, loose associations, ambivalence, or emotional lability) but are thought to be less effective for negative symptoms (such as decreased motivation and lack of emotional expressiveness). The antipsychotics are also sometimes called "neuroleptics" because they can cause side effects that affect the neurologic (nervous) system (extrapyramidal side effects).
Since 1989, a newer class of antipsychotics affecting both dopamine and serotonin (atypical antipsychotics or second generation antipsychotics [SGA]) has been introduced. At clinically effective doses, they are less likely to cause the neurologic side effects but are more likely to cause weight gain and may have an effect on metabolism (diabetes and cholesterol).
The first of the atypical antipsychotics, clozapine (Clozaril, Fazaclo), is the only agent that has been shown to be effective where other antipsychotics have failed. It is also the only antipsychotic drug shown to reduce suicide rates associated with psychosis. Clozapine rarely causes extrapyramidal side effects, but it does have other rare but serious side effects, including a possible decrease in the number of white blood cells (agranulocytosis), so the blood needs to be monitored every week during the first six months of treatment and at least monthly as long as someone is taking the medication to catch this side effect early if it occurs. Other atypical antipsychotics include risperidone (Risperdal, Risperdal M-tab), olanzapine (Zyprexa, Zyprexa Zydis), quetiapine (Seroquel and Seroquel-XR), ziprasidone (Geodon), aripiprazole (Abilify), paliperidone (Invega), asenapine (Saphris), iloperidone (Fanapt), lurasidone (Latuda), cariprazine (Vraylar), and brexpiprazole (Rexulti). The use of these medications has allowed successful treatment and release back to their homes and the community for many people suffering from schizophrenia.
Most of these medications take two to four weeks to have a full 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).
Because many people with schizophrenia stop taking their medications, increasing their risk of future psychotic episodes, long-acting injectable medications have also been used. These injectable forms of antipsychotics avoid the need for daily pills, and since they provide a steady level of medication in the bloodstream, people with schizophrenia may avoid some of the side effects due to peak medication levels with pills. From the first-generation antipsychotics, both haloperidol (Haldol) and fluphenazine (Prolixin) have injectable forms that are given every two to four weeks. Over the past few years, more options from the second-generation antipsychotics have been developed. There are now long-acting injectable versions of risperidone (Consta, injections every two weeks), paliperidone (Sustenna, every four weeks), olanzapine (Relprevv), and aripiprazole (Aristada, every four to six weeks) and Maintenna (every four weeks). Most recently, a long-acting version of paliperidone requiring injections every three months (Trinza) was released.
People with schizophrenia may also develop major depressive disorder (depression) or bipolar affective disorder. When these mood disorders are present for a substantial percentage of the time and cause significant impairment, the diagnosis of schizoaffective disorder (depressive or bipolar type) may be given. Mood disorders in people with schizophrenia would be treated with the same medications used for those diagnoses alone. Antidepressant medications, including 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. For bipolar disorder, mood stabilizers, such as lithium, valproate (Depakote, Depakene), carbamazepine (Tegretol) or lamotrigine (Lamictal), may be added to antipsychotic medications.
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 the schizophrenia sufferer or 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.