Neuroleptics remain the treatment of choice for schizophrenia. They are divided into 2 separate classes, typical antipsychotics, which are the older and less expensive medications, and atypical antipsychotics, which are newer and more expensive.
It is important to understand that there are risks and benefits with every medication. Patients may need to try more than one drug or combine medications to get the right treatment.
Common names include: ChlorpromazineFluphenazineHaloperidolPerphenazineThioridazineThiothixeneTrifluoperazine
Typical antipsychotics are often very effective in treating certain symptoms (commonly referred to as positive symptoms) of schizophrenia, particularly hallucinations and delusions. Unfortunately, they may not be as helpful with other symptoms (known as negative symptoms), such as reduced motivation, apathy, and a lack of emotional expressiveness.
Typical antipsychotics can produce side effects that resemble the more difficult to treat negative symptoms. Often, lowering the dose or switching to a different medication may reduce these side effects. Patients may have difficulty complying with these medications as they may produce significant side effects.
Possible side effects of typical antipsychotics include: Drowsiness and fatigueRestlessnessMuscle spasmsTremorDry mouthBlurring of visionSexual dysfunction and/or loss of interest in sexSudden drop in blood pressure—hypotension
Gastrointestinal problems (nausea, vomiting,
Galactorrhea—the production of milk, particularly in malesGynecomastia—the appearance of breast tissue in males unrelated to weightDifficulty with urination
Many of these side effects can often be corrected by lowering the dosage or controlled by the addition of other medications. Patients may have unique responses and experience different side effects to various antipsychotic drugs.
A possible, serious, long-term side effect with any typical antipsychotic is
(TD). TD is a disorder characterized by involuntary movements, most often affecting the mouth, lips, and tongue, and sometimes the trunk or other parts of the body such as arms and legs.
In most cases, the symptoms of TD are mild, and the patient may be unaware of the movements. When the symptoms are severe, though, they can be disconcerting to both the patient and others. In this case, the patient may be switched to a different antipsychotic. The course of TD is extremely variable. If detected early, the chance of the side effect becoming milder or disappearing is greatly increased. Unfortunately, for many patients, the abnormal movements seen in TD are permanent.
Common names include: AripiprazoleAsenapineBrexipiprazoleCariprazineClozapineIloperidoneLurasidoneOlanzapinePaliperidoneQuetiapineRisperidoneZiprasidone
Atypical antipsychotics are equally effective in treating the positive symptoms of schizophrenia, such as hallucinations and delusions. Unlike typical antipsychotics, atypical antipsychotics may also treat the negative symptoms of schizophrenia, such as apathy, listlessness, restlessness, and social withdrawal. There is some evidence that some atypical antipsychotics are effective at treating
Atypical antipsychotics tend to have fewer dyskinetic side effects than typical psychotics. It may take several weeks to months before atypical antipsychotics produce the desired treatment effects. There is recent evidence to suggest that this type of medication can produce a significant amount of weight gain (with the exceptions of ziprasidone and aripiprazole). Atypical antipsychotics also have been linked to the development of
diabetes cholesterol, and
Clozapine, the first atypical antipsychotic developed, is a very effective treatment for schizophrenia. The drug's use has been limited because approximately 1% of individuals who take it will develop a life threatening side effect called
(a severe decrease in the white blood cell count), which can make one highly susceptible to developing infections. Clozapine is only used if a patient has not responded to 2 adequate trials of other antipsychotics. Any patient taking clozapine is required to have their blood drawn weekly in order to monitor white blood cell counts.
Possible side effects of typical antipsychotics include: Weight gainIncrease in cholesterol, triglycerides, and blood sugarMetabolic syndromeDiabetesLow blood pressureDrowsinessConstipationSexual dysfunction and/or loss of libidoGalactorrhea (primarily seen with risperidone)Tardive dyskinesia (The exact risk of developing TD with the use of atypical antipsychotics has not yet been determined.)
Antipsychotic medications, in rare cases, can cause a condition called neuroleptic malignant syndrome (NMS). This life-threatening condition can occur in up to 1% of people taking these medications. It typically occurs within the first 2 weeks of treatment, but can occur later. Symptoms include fever, sweating, muscle stiffness, and lightheadedness. This condition requires immediate medical care.
Compliance with medication tends to be a problem in people with schizophrenia for a variety of reasons. Fortunately, there are many strategies that patients, doctors, and families can use to improve adherence and prevent worsening of the illness. Some antipsychotic medications, including haloperidol, fluphenazine, perphenazine, risperidone, and others, are available in long-acting injectable forms that eliminate the need to take pills every day.
Medication calendars or pillboxes labeled with the days of the week can help patients and caregivers know when medications have or have not been taken. Using electronic timers that beep when medications should be taken, or pairing medication with routine daily events like meals, can help patients remember and adhere to their dosing schedule. Encouraging family members to actually observe daily medication intake can greatly increase adherence. In addition, to these adherence strategies, patient and family education about schizophrenia is an important part of any successful treatment process.