Is There a “Right” Medicine for Everyone?
The large majority of people with schizophrenia experience substantial improvement when treated with antipsychotic agents, but finding the best medications may take time. Drug therapy for schizophrenia often falls into two stages: the initial or acute phase and the long-term or maintenance phase. The acute phase is often brought about by a psychotic episode and sometimes requires higher doses of anti-psychotic drugs to relieve the symptoms.
If possible, it is preferable to treat a patient experiencing a first psychotic episode with as low an effective dose of antipsychotic medication as possible to limit chances of side effects. If a person experiences the stress of a psychotic episode and soon after comes to associate an unpleasant side effect with treatment, he will be more likely to avoid treatment in the future.
Doctors may prescribe an anti-anxiety medication or minor tranquilizer, such as Ativan (lorazepam), Xanax (alprazolam), Klonopin (clonazepam), or Valium (diazepam) for a few weeks after starting antipsychotic drug therapy. Until the antipsychotic drug becomes fully effective, anti-anxiety medications can reduce agitation and calm the patient as he recovers from the trauma of his psychotic experience.
Question
What are minor tranquilizers?
Also called anxiolytics, or anti-anxiety agents, minor tranquilizers are medications that reduce tension and relieve anxiety. The best known belong to a group of chemicals called benzodiazepines. They are useful for calming people under physical and psychological stress. They reduce feelings of fear and agitation at least in part by increasing the activity of a chemical messenger in the brain called GABA (gamma-Aminobutyric acid).
Other adjunct medications, such as Cogentin (benztropine) or Artane (trihexyphenidyl), are used to reduce problems with extra-pyramidal side effects. These medications, however, may sometimes cause side effects of their own, including constipation, difficulty urinating, and blurry vision. Older patients may be particularly vulnerable to these side effects. If side effects don't present a problem, both benzodiazepine and Cogentin or Artane can be dropped from the drug lineup as the antipsychotic medicine exerts its full therapeutic effect.
Newer, atypical antipsychotic medications are also prescribed for treating initial psychotic episodes. Many doctors believe they are preferable because they have few or no extrapyramidal side effects, and adjunctive treatment with benztropine may not be required.
Once symptoms are under control, the patient enters the maintenance phase, in which doses are reduced as much as possible to minimize the side effects while continuing to prevent the recurrence of acute psychotic episodes. The maintenance phase may be lifelong for many individuals.
Essential
Medications can interact in dangerous ways. Avoid harmful drug combinations by making a list of all prescribed drugs, over-the-counter medicines, herbal remedies, vitamins, and supplements that someone with schizophrenia is taking. Show the list to your doctor and your pharmacist. They can determine if there is a danger of harmful interactions.
Finding a good match between a patient and a particular medication for the maintenance phase is a trial-and-error process. Different individuals often respond differently to the same drug.
Example of a Treatment Plan
Antipsychotic medications typically start working in the first week of treatment, but they may require up to three months to be fully effective. It may take considerable effort to hit on the right treatment, but try not to get discouraged.
Adjunctive agents such as diazepam or lorazepam may be prescribed if the patient experiences restlessness due to the antipsy-chotic therapy. This side effect may also be effectively treated with propranolol (Inderal), a medication known as a heart and blood pressure medicine, or Benadryl (phenhydramine), a well-known antihistamine or anti-allergy medicine.
In The Essential Guide to Psychiatric Drugs, Jack M. Gorman, MD, advises continuing the antipsychotic medication for one year after the initial stabilization of symptoms if the patient has a history of one psychotic episode, and for several years if he has had two or more episodes. If a patient forgets, refuses, or is unable to take daily medication, a long-lasting injectable version of Haldol (Haldol Decanoate), Prolixin Decanoate, or Risperdal (Risperdal Consta) may be tried.
The American Psychiatric Association's guidelines for initial treatment of schizophrenia suggest starting with atypical antipsy-chotic agents. For treatment of the first psychotic episode, the APA guidelines suggest trying risperidone, olanzapine, quetiapine, ziprasi-done, or aripiprazole (one of the new or second generation drugs). It recommends considering clozapine in patients who do not respond to other treatments or have persistent, chronic, and unrelenting suicidal thoughts or behavior. Some of the atypical antipsychotics might also benefit patients with tardive dyskinesia, a side effect involving involuntary movements.
The Group 2 drugs could be considered if the patient has a history of extrapyramidal side effects, but they should avoid high doses of risperidone. Patients who gain weight easily, have high blood sugar, or show high cholesterol in the blood might respond better to ziprasidone or aripiprazole. Again, patients who repeatedly fail to take their medications can be treated with long-lasting injectable formulations of antipsychotic drugs that may be given once every two to four weeks. Of course, regular monthly visits to the doctor will help spot side effects such as tardive dyskinesia, weight gain, or diabetes.
