Antipsychotic Medications The word psychosis is used to describe conditions that affect the mind, causing a loss of contact with reality. Psychosis is most likely to occur in young adults and is quite common. Psychosis can happen to anyone. Like any other illness, it can be treated. Most make a full recovery.
Types of psychotic disorders include:
Schizophrenia Schizophreniform disorder Schizophreniform Schizoaffective disorder Delusional disorder Brief psychotic disorder People with mood disorders such as major depression and bipolar disorder also may have psychotic symptoms.
Symptoms of psychosis Psychotic disorders are characterized by hallucinations, delusions, personality disorganization, loss of ego boundaries and/or the inability to meet the ordinary demands of life. A person who is psychotic is out of touch with reality. The patient may "hear voices" or have strange and untrue ideas (for example, thinking that others can hear their thoughts, or are trying to harm them, or that the patient is the president of the United States or is some other famous person). The patient may get excited or angry for no apparent reason or spend a lot of time alone or in bed, sleeping during the day and staying awake at night. Patients may neglect their appearance, not bathing or changing clothes and may become difficult to communicate with, saying things that make no sense or barely talking at all. Symptoms vary from person to person and may change over time. The most common form of psychotic disorders is schizophrenia.
Antipsychotics work against these symptoms. These medications cannot "cure" the illness, but they can take away many symptoms or make them milder. In some cases, they can shorten the course of the illness as well.
A number of antipsychotics are available. The main differences are in the potency (the dosage prescribed to produce therapeutic effects) and side effects. Some people might think the higher the dose, the more serious the illness. But this is not always true.
A doctor considers several factors when prescribing an antipsychotic besides how "ill" someone is. These include:
Age Body weight Type of medication Past history If a person took a particular medication before and it worked, the doctor is likely to prescribe the same one again. Some less potent drugs, like chlorpromazine (Thorazine®), are prescribed in higher numbers of milligrams than others of high potency, such as haloperidol (Haldol®).
If a person has to take a large amount of a "high-dose" antipsychotic, such as chlorpromazine, to get the same effect as a small amount of a "low-dose" medication, such as haloperidol, it may be difficult to understand why the doctor doesn't just prescribe "low-dose" medications. The main reason is the difference in their side effects. These medications vary in their side effects, and some people have more trouble with certain side effects than others. A side effect may sometimes be desirable. For instance, the sedative effect of some antipsychotics can help patients who have trouble sleeping or who become agitated during the day.
Unlike some prescription drugs that must be taken several times during the day, antipsychotics usually can be taken once a day. Thus, patients can reduce daytime side effects by taking the medications before bed. Some antipsychotics are in forms that can be injected once or twice a month, thus assuring that the medicine is being taken.
Side effects Many common side effects go away after the first few weeks of treatment. These include drowsiness, rapid heartbeat and dizziness when changing position.
Some people gain weight while taking antipsychotics and may have to change their diet to control their weight. Other side effects that may be caused by some antipsychotics include:
Decrease in sexual ability or interest. Problems with menstrual periods. Easily sunburned. Skin rashes. If a side effect is especially troublesome, talk with the doctor who may prescribe something different, change the dose or schedule, or add another medication to control side effects.
Muscular side effects Movement difficulties may occur with antipsychotics, although most of them can be controlled with an anti-cholinergic medication. These movement problems include:
Muscle spasms of the neck, eye, back or other muscles. Restlessness and pacing. A general slowing down of movement and speech. A shuffling walk. Some side effects may look like psychotic or neurologic (Parkinson's disease) symptoms, but they aren't. If they are severe or last with continued treatment with an antipsychotic, call the doctor who might either change the medication or prescribe an additional one to control the side effects.
Ending treatment Just as people vary in their responses to antipsychotics, they also vary in how quickly they improve. Some symptoms go away within days while others take weeks or months. For many patients, substantial improvement is seen by the sixth week of treatment, although this is not true in every case. If someone does not seem to be getting better, a different type of medication may be tried.
Even if a person feels better or completely well, medication should not be stopped without a doctor's supervision. Some people may need to take medication for an extended period or even indefinitely. These people usually have chronic (continuous) schizophrenic disorders or have a history of repeated schizophrenic episodes and are likely to become ill again. Also, in some cases, a person who has had one or two severe episodes may need medication indefinitely. In these cases, medication may be continued in as low a dosage as possible to control of symptoms. This approach called maintenance treatment prevents relapse in many people and removes or reduces symptoms for others.
Maintenance treatment While maintenance treatment is helpful for many, a drawback for some is the chance of developing long-term side effects, particularly a condition called tardive dyskinesia. This condition is characterized by involuntary movements. These abnormal movements most often occur around the mouth but are sometimes seen in other muscle areas such as the trunk, pelvis or diaphragm. The disorder may be mild or severe. For some people, the condition cannot be reversed, while others recover partially or completely. Tardive dyskinesia is seen most often after long-term treatment with antipsychotics. There is a higher incidence in women, with the risk rising with age. There is no way to tell if someone will develop this condition and if it develops, whether the person will recover. No effective treatment for tardive dyskinesia exists. The possible risks of long-term treatment with antipsychotics must be weighed against the benefits in each individual case by patient, family and doctor.
Medication interactions Antipsychotics can create unwanted effects when taken with other medications. Therefore, the doctor should be told about all medicine being taken, including over-the-counter drugs, and the use of alcohol. Some antipsychotics interfere with high blood pressure medications, anticonvulsants (taken for epilepsy) and medications used for Parkinson's disease. Some antipsychotics add to the effects of alcohol and other central nervous system depressants, such as antihistamines, antidepressants, barbiturates, some sleeping and pain medications, and narcotics.
Neuroleptics Typical neuroleptics are the traditional mainstay of treatment for psychosis. If someone refers to "older" antipsychotics, they are likely referring to the typical neuroleptics. These drugs block various dopamine receptors (nervous system chemicals) in the brain. Along with controlling psychosis, lower dopamine levels also affect the motor system, causing unwanted muscular side effects.
Atypical antipsychotics
Since the introduction of Clozaril, several other newer generation antipsychotics have become available. These include Zyprexa® (olanzapine), Risperdal® (riseridone), Seroquel® (quetiapine), Geodon® (ziprasidone) and Abilify® (aripiprazole). This class, called atypical antipsychotics, now represent first-line treatments. This means when the person is first diagnosed, the doctor will choose these drugs first before trying others. These medications are as effective as the traditional antipsychotics, but they tend to be better tolerated. They are believed to work by balancing chemicals in the brain. Overall, the side effects are reduced. However, the problems associated with the traditional antipsychotics may be less common with the newer medications. Some newer medications have been associated with weight gain, high cholesterol and the development of diabetes.
Trade Name Generic Name What Makes It Different Common Side Effects and Precautions Zyprexa olanzapine Can be injected into the muscle, Can improve hallucinations, delusions, disorganized thinking. Can improve mania and depression associated with bipolar disorder. Immediate-acting injection formulations are available. Dissolvable tablet formulations are also available. Drowsiness, dry mouth, dizziness, feelings of weakness constipation, stomachache, increased appetite, weight gain or mild trembling. Tell your doctor if you have a history of seizures. Smoking can interfere with how much of the drug gets into the body. Risperdal (Consta and M-Tab) riseridone Treats symptoms such as hallucinations, delusions, disorganized thinking. Can also improve lack of emotion, speech and motivation. May be used for bipolar. May help symptoms of agitation in older people with memory loss or people with developmental problems, and children with certain mental illnesses. A long-acting injection formulation is available for Risperdal Consta. Dissolvable tablet formulations re available for Risperdal M-Tab. Generally well tolerated: Anxiety, sleepiness, restlessness, tremors, and muscle stiffness; dizziness, constipation, nausea, indigestion, runny nose, rash and rapid heartbeat. May be associated with strokes in older people with dementia. May develop tardive dyskinesia. Seroquel quetiapine Can treat agitation and severe anxiety in people with different types of psychotic illnesses. Can help with delusions, thought disorder and hallucinations and can improve social withdrawal, lack of energy, apathy and reduced ability to express emotion. Can also treat bipolar disorder. Although rare, may cause possibly deadly neuroleptic malignant syndrome (muscle rigidity and fever). Other serious side effects, which have been reported, include tardive dyskinesia, high blood sugar and diabetes. Has been associated with low levels of thyroid.
Common side effects: drowsiness, dry mouth, dizziness, constipation, weakness, abdominal pain, sudden drop in blood pressure when standing, sore throat, abnormal liver tests, stomachache, and weight gain. Geodon ziprasidone May improve symptoms of depression in people with schizophrenia. May help auditory hallucinations, delusions and thought disturbances. May also help with social withdrawal, motivation and inability to feel pleasure. Being studied for bipolar. Immediate-acting injection formulations are available. Drowsiness, nausea, constipation, dizziness, tremors, diarrhea, rash, restlessness, runny nose. May cause a potentially deadly heart rhythm problem, but since introduction to the U.S, no deaths related to Geodon. Do not take with thioridazine, quinidine, moxifloxicin, pimozide and sparfloxicin, and certain high blood pressure medications. Abilify aripiprazole Can improve symptoms such as hallucinations, delusions and disorganized thinking. May help improve social isolation, speech and motivation. Being studied for treatment in bipolar. An oral solution is available. Generally well-tolerated: headache, stomachache, constipation, nervousness, sleep problems or dizziness.
Although rare, may cause the possibly deadly neuroleptic malignant syndrome (muscle rigidity and fever) Other serious side effects, which have been reported, include tardive dyskinesia, high blood sugar and diabetes.
For some people, hyperglycemia went away when the drug was stopped, but others needed treatment for diabetes even after coming off the drug. Patients with diabetes who are started on atypical antipsychotics should be checked regularly for worsening of blood sugar (glucose) control.
Patients who have diabetes risk factors, such as obesity or a family history of diabetes, should have fasting blood glucose testing when treatment starts and periodically thereafter.
Everyone treated with atypical antipsychotics should be checked often for hyperglycemia symptoms, such as excessive thirst, excessive appetite, frequent urination or weakness. If symptoms develop while someone is on these drugs, they should have a fasting blood glucose test.
Atypical antipsychotics are not approved for the treatment of patients with dementia-related psychosis.
Sources: National Institute of Mental Health
National Alliance for the Mentally Ill
The Food and Drug Administration
This article was reviewed June 2007 by PHYLLIS CROSS.
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