In schizophrenia, antipsychotic medications are proven effective in treating acute psychosis and reducing the risk of future psychotic episodes. The treatment of schizophrenia thus has two main phases: an acute phase, when higher doses might be necessary in order to treat psychotic symptoms, followed by a maintenance phase, which is usually life-long. During the maintenance phase, dosage is often gradually reduced to the minimum required to prevent further episodes and control inter-episode symptoms. If symptoms reappear or worsen on a lower dosage, an increase in dosage may be necessary to help prevent further relapse.
Even with continued treatment, some patients experience relapses. The most common cause of a relapse is stopping medications.
The large majority of schizophrenia patients experience improvement when treated with antipsychotic drugs. Some patients, however, do not respond to medications, and a few may seem not to need them.
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.
Antipsychotic drugs are the cornerstone in the management 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 better quality of life, and enjoy an improved outlook. The choice and dosage of medication is individualized and is best done by a physician who is well trained and experienced in treating severe mental illness.
The first antipsychotic drug was discovered by accident and then used for schizophrenia. This was chlorpromazine (Thorazine), which was soon followed by medications such as fluphenazine (Prolixin), haloperidol (Haldol), loxapine (Loxapine), perphenazine (Trilafon), thioridazine (Mellaril), thiothixene (Navane) and trifluoperazine (Stelazine). These drugs have become known as “neuroleptics” (meaning, “take the neuron”) because, although effective in treating positive symptoms (acute symptoms such as hallucinations, delusions, thought disorder, loose associations, ambivalence, or emotional lability), they can cause cognitive dulling and involuntary movements, among other side effects. These older medications also are not so effective against so-called negative symptoms such as apathy, decreased motivation, and lack of emotional expressiveness.
In 1989, a new generation of antipsychotics — called atypical or second generation antipsychotics — was introduced. At the correct doses, fewer of the neurological side effects — which often include such symptoms as muscular rigidity, painful spasms, restlessness, or tremors — are seen.
The first of the new generation, clozapine (Clozaril) is the only drug that has been shown to be effective where other antipsychotics have failed. It is less strongly linked with the side effects mentioned above, but it can produce other side effects, including weight gain, changes in blood sugar and cholesterol, and possible decrease in the number of infection-fighting white blood cells. Blood counts need to be monitored every week during the first six months of treatment and then every two weeks and eventually once a month indefinitely in order to catch this side effect early if it occurs.
Other atypical antipsychotics include: aripiprazole (Abilify), aripiprazole lauroxil (Aristada), asenapine (Saphris), brexpiprazole (Rexulti), cariprazine (Vraylar), lurasidone (Latuda), paliperidone (InvegaInvega Sustenna, Invega Trinza), paliperidone palmitate (Invega Trinza), quetiapine (Seroquel), risperidone (Risperdal or Risperdal Consta), olanzapine (Zyprexa), and ziprasidone (Geodon). Another atypical antipsychotic, iloperidone (Fanapt), has been FDA-approved for acute (but not long-term) treatment of schizophrenia. The use of all of these medications has allowed successful treatment and release back to their homes and the community for many people suffering from schizophrenia.
Although sometimes more effective and better tolerated than older conventional neuroleptics, atypical antipsychotics also have side effects, and current medical practice is developing better ways of understanding these effects, identifying people at risk, and managing complications. Importantly, all atypical antipsychotics carry the possible risk for causing weight gain and raising blood sugar, cholesterol, and triglyceride levels, which must be periodically monitored during treatment. Some antipsychotics — typical and atypical — can cause heart rhythm problems that may require monitoring by a doctor.
Most of these medications take at least two to four weeks to take 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 four weeks (or even as long as several months in the case of clozapine).
Patients successfully treated with monthly Invega Sustenna for 4 months can opt instead to be treated with Invega Trinza. Invega Trinza is the first and only antipsychotic that can be administered just four times a year.
Because the risk of relapse of illness is higher when antipsychotic drugs 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 towards 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.