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Medication for Schizophrenia

The Scottish Office and the NHS in Scotland issued a publication "Services for People affected by Schizophrenia. A Good Practice Statement" in 1995. The subject "Medication for Schizophrenia" was discussed at the NSF(S) Members Day on 28th May, 1996 using this Good Practice booklet as source material.

The following is therefore NSF(S)'s interpretation of that material.

Neuroleptic drugs are commonly the medication used to control the florid symptoms of schizophrenia, such as delusions, hallucinations and thought disorders. Negative symptoms (apathy, lack of motivation) may not be improved by drug treatments although some newer drugs are more helpful.

First Episodes

People who are thought to be developing schizophrenia will be referred to specialist psychiatric services and many will need admission to an acute psychiatric ward.
Giving medication and controlling it may only be feasible in hospital. However, to make assessment and diagnosis easier, medication may sometimes be avoided during the initial period of observation.

In Hospital

A thorough physical medical examination is made, and from a single blood sample, a full blood picture is obtained and laboratory tests covering renal, liver, thyroid and other functions are carried out. Tests may also reveal the excessive use of alcohol or the presence of "street drugs".

During the stay in hospital, in addition to drug treatment, psychosocial therapies should be available, for individuals or groups. These therapies may include behavioural psychological treatment to help patients deal with delusions and hallucinations, anxiety, phobic avoidance, obsessional thinking and compulsions.

Successful drug treatment permits subsequent participation in a range of non-drug therapies.

Facts about Drugs

A small number of illnesses settle rapidly without medication.

In a first episode, drugs are given orally to give the doctor fine control over dosage which can be adjusted rapidly or stopped if there are bad side effects. Later, depot drugs, given by injection can have effects lasting for a few weeks.

"Mega doses" usually don't help. They can increase sedation and side effects.
For the majority, relatively modest doses can be effective against acute symptoms.

Adequate time is needed to allow the desired therapeutic response to develop. It is good practice to change the dose gradually, balancing wanted and unwanted effects.

Although the use of one drug is best to minimise drug interactions and simplify observation, a few people respond well to a combination of drugs. The need for additional medication must be monitored and need rarely be used long-term.

Side Effects

All patients do not necessarily suffer all these side-effects. Possible side effects include Parkinsonism, dystonia (cramp-like muscle contractions), akathisia (inner restlessness), tardive dyskinesia (involuntary movements which may develop later), postural hypertension, blurring of vision, weight gain, reduction in sex drive.
Movement disorders can be helped by giving a smaller dose of the drug, by changing to another drug, or by the addition of a drug which reduces side effects (the last should be used briefly and be reviewed regularly).

Compliance with Treatment

Patients are more likely to stick to their drug treatment if they and their carers have a clear understanding of the treatment and side-effects and where rapid attention is given to drug side- effects.

Poor compliance is associated with the user's perception of distressing side-effects. When the condition is stabilised, gradual dose reduction may improve compliance.

It can take two or three months before drug treatment is fully effective. Likewise it can take two or three months for signs of relapse to appear after treatment is stopped.

Treatment Resistance

Treatment resistance is not likely to be helped by large doses. Diagnosis should be reviewed and psychology treatment tried.

Clozapine may be helpful but it needs to be monitored. It has 2 serious side-effects, agranulocytosis (2% of patients may have low white blood count), and epileptic seizures (5% of patients on doses over 600mg.). The high cost of clozapine can be balanced against an improved quality of life and less time spent in hospital.

Where drugs produce severe side-effects, other new drugs may offer a better balance between risk and benefit. Some new drugs are currently being tested.

Discharge from Hospital

Psychiatric hospitals should have clear procedures for planning the discharge of all vulnerable patients. Some will get the Care Programme Approach which is the formal procedure for discharge. Such procedures promote good practice, covering both drug treatment and community care.

Long-term care focuses on minimising chronic symptoms, improving the quality of life and psychological and social wellbeing, and the prevention of relapse.

Prevention of Relapse

CPNs, GPs and families are improving in monitoring drug treatment and in helping compliance and this may prevent relapse.

Maintenance therapy doses are usually lower than in the acute period. Regular specialist review should monitor the dosage and side-effects.

Too low a dose of medication may lead to relapse, often some time after the dose is lowered. Necessary adjustments should be made as quickly as possible, when the earliesr signs of relapse become evident.

Stopping and starting medication can be effective in the first year but is later linked with a higher relapse rate.

Should drug treatment be stopped for any reason it is important to keep in close touch with the GP, Outpatient Clinic or CPN, so that treatment can be started again as quickly as possible in the event of relapse.