biological treatment for schizophrenia: drug therapy

Question 1

what is drug therapy based upon?

Answer 1

• dopamine hypothesis

Question 2

what do conventional antipsychotics aim to reduce?

Answer 2

• positive symptoms of schizophrenia
• the drugs bind to the dopamine receptors but don’t stimulate them
• blocks the sites meaning dopamine can’t affect neurons

Question 3

antipsychotic drugs are proven effective in treating…

Answer 3

• acute psychosis
• reducing risk of future psychotic episodes

Question 4

what are the two main phases of schizophrenia treatment?

Answer 4

• acute phase
• maintenance phase

Question 5

describe the acute phase

Answer 5

• high doses may be necessary in order to treat psychotic symptoms

Question 6

describe the maintenance phase

Answer 6

• followed from acute phase
• usually life long
• during phase, dosage is gradually reduced to minimum required in order to prevent further eps and control inter-eps symptoms

Question 7

what happens if symptoms reappear or worsen on lower dosage?

Answer 7

• increase in dosage may be necessary to help prevent further relapse
• even with continued treatment, some patients experience relapse

Question 8

what is the most common cause of a relapse?

Answer 8

• stopping medications

Question 9

what would doctors prescribe in terms of schizophrenia?

Answer 9

• typical antipsychotic medication, eg haloperidol or chlorpromazine, following first psychotic ep
• will only try one drug at a time
• monitor patients carefully for side effects and changes in symptoms

Question 10

when do drug treatments need to be started?

Answer 10

• quickly in order to be most effective
• patients who remain untreated for many years often don’t benefit when treatments start

Question 11

what happens when symptoms don’t improve with typical anti psychotics?

Answer 11

• atypical antipsychotics eg clozapine or risperidone might be used

Question 12

why’s it not as simple for there to be one drug per disorder?

Answer 12

• patients react differently to treatments
• doctors have own preferences developed through experience with other patients

Question 13

what are the drugs used to treat schizophrenia called?

Answer 13

• antipsychotic drugs
• work to suppress hallucinations and delusions
• atypical and typical

Question 14

what are typical drugs?

Answer 14

• first generation antipsychotics (FGAs)
• well established

Question 15

what are atypical drugs?

Answer 15

• second generation antipsychotics (SGAs)
• newer and less widely used
• fewer side effects and act in different ways to typical
• seem to be better for treating negative symptoms and for improving cognitive functioning

Question 16

how many drugs is a patient supposed to take?

Answer 16

• only ever on one psychotic drug at a time (antidepressants can be taken at same time)
• one drug does not treat each mental illness - depending on individual response and clinician’s preference

Question 17

when to antipsychotics drugs tend to reduce positive symptoms?

Answer 17

• 2 weeks

Question 18

how could patients take the antipsychotic?

Answer 18

• tablet or syrup form
• if patients forget to take, medical practitioners can inject the antipsychotic

Question 19

chlorpromazine: is it atypical or typical? how does it work?

Answer 19

• typical
• blocks dopamine receptor sites and thus decreases dopamine activity

Question 20

chlorpromazine: what are the side effects?

Answer 20

• muscle tightening in neck and jaw
• tardive dyskinesia
• decrease of spontaneous movement
• decrease in emotional spontaneity and motivation
• motor restlessness and fidgeting
• sedation
• dry mouth
• constipation
• weight gain
• neuroleptic malignant syndrome (fatal)

Question 21

chlorpromazine: evidence

Answer 21

• barlow and durand
• effective in reducing symptoms in about 60% of cases
• most impact on positive symptoms
• treated patients may still suffer severe negative symptoms

Question 22

haloperidol: is it atypical or typical? how does it work?

Answer 22

• typical
• blocks dopamine receptors site thus decreasing dopamine activity

Question 23

haloperidol: what are the side effects?

Answer 23

• muscle tightening in neck and jaw
• tardive dyskinesia
• decrease of spontaneous movement
• decrease in emotional spontaneity and motivation
• motor restlessness and fidgeting
• sedation
• dry mouth
• constipation
• weight gain
• neuroleptic malignant syndrome (fatal)
• schooler et al: 55% relapse rate

Question 24

haloperidol: evidence

Answer 24

• schooler et al
• randomly allocated 555 patients in first ep of schizophrenia
• either treatment with haloperidol or risperidone (atypical)
• both groups 75% showed reduction in symptoms

Question 25

clozapine: is it atypical or typical? how does it work?

Answer 25

- **atypical** - blocks both **dopamine (D2) and serotonin (5-HT2A) receptor sites**

Question 26

clozapine: what are the side effects?

Answer 26

- similar to typical antipsychotics but **tardive dyskinesia** is much **reduced** - fewer side effects than typical or FGAs - rare side effect: **agranulocytosis** - dangerously low levels of **white blood cells** (fatal)

Question 27

clozapine: evidence

Answer 27

- **pickar et al** - compared **clozapine** with other **neuroleptics and placebo** - found that **clozapine** is **most effective** in **reducing symptoms**, even in patients who has previously been **treatment resistant**

Question 28

risperidone: is it atypical or typical? how does it work?

Answer 28

- **atypical** - blocks both **dopamine (D2) and serotonin (5-HT2A) receptor sites**

Question 29

risperidone: what are the side effects?

Answer 29

- lower **relapse rate** than haloperidol: **45%** compared to **55%** (schooler et al) - fewer **side effects** than haloperidol - weight gain - severe **anxiety** - sedation - insomnia - sexual dysfunction - low blood pressure - muscle stiffness - muscle pain - tremors - increased salivation and stuffy nose - also associated with **diabetes** - increased risk of **suicide and tumours**

Question 30

risperidone : evidence

Answer 30

- **emsley** - patients injected with **risperidone early in course of disorder** had **low relapse rates** and **high remission rates**: - **84%** of patients showed at least **50%** showed **reduction in both positive and negative**

Question 31

supporting: guo et al

Answer 31

- studied **7 antipsychotic drugs** in china - **1133** patients in **first 5 years of schizophrenia** - looked at how many **stopped taking the drugs** - **no big difference** in stopping rates between drugs - **risperidone** stop rate was **40.2%** - **clozapine** stop rate was **36.7%** - all 7 drugs were **similar in effectiveness** based on this measure

Question 32

supporting: meltzer et al

Answer 32

- **481 patients** randomly put into groups - given **placebo**, **4 new drugs or haloperidol for 6 weeks** - tested **positive and negative symptoms** and **illness severity** - **haloperidol** improved **all areas** compared to placebo - 2 new drugs helped in some areas - 2 new drugs did not help - shows **drug treatments can work** to some extent

Question 33

evidence: hartling et al

Answer 33

- reviewed **114 studies over 2 years** (meta analysis) - **few differences** in treating core symptoms - **haloperidol** better than olanzapine for **positive symptoms** - **olanzapine** better than haloperidol for **negative symptoms** - higher risk of **tardive dyskinesia** with **chlorpromazine** than clozapine - could not say one generation of drugs was better overall