treatments
Treating Refractory Schizophrenia
Introduction
The effective treatment of refractory Schizophrenia demands that we consider a number of aspects of treatment that may influence the ultimate outcome for each patient.
Optimal Dosage
When patients with Schizophrenia are currently taking medication, but experience persistent symptoms, it is useful to insure that they are receiving maximum benefit from their current medication.
Provided they can tolerate further increases in their current medication in terms of side effects, the dose should be increased on a trial basis.
This should include doses of both oral agents and any depot forms of medication (Risperdal Consta, Haldol Decanoate or Prolixin Decanoate).
Since it may take some time for the dosage increase to result in a decrease in symptoms, patients and their families must be patient during this period.
Alternative Medications
If patients have explored only a limited number of antipsychotic medications, but remain symptomatic, other agents should be considered. They is generally investigated by systematically adding additional agents to their current regimen (recipe of medications).
This cautious introduction ensures that the patient tolerates the new drug and minimizes the risk for decompensation (increased symptoms), since it is likely that the current medications are at least partially effective in controlling symptoms.
If the new drug is tolerated and appears to be helpful, the older drug can be carefully tapered and discontinued. Often, it becomes clear that the patient achieved the best control of their symptoms with both drugs and their doctor will elect to continue with the combination.
It should be noted that the maximum doses of antipsychotic medications listed in the PDR (Physician's Desk Reference) or the package insert only reflect the range of doses that most patients respond favorably to. It is not unusual for psychiatrist to explore higher doses if this is justified by the patient's symptoms. If higher doses are effective, they will likely be continued unless intolerable or dangerous side effects are encountered. In those cases, alternative medications must be explored or efforts must me make to reduce or avoid side effects.
Augmentation
If patients are currently taking the maximum doses of medications that they can tolerate, but continue to experience symptoms, augmentation should be considered.
Augmentation or combined therapy is the addition of a second agent, either another atypical antipsychotic, a typical antipsychotic, other unrelated drugs, such as mood stabilizing agents (Lithium, Depakote, Tegretal and others) or antidepressants.
Combining medications may increase side effects and necessitate a reduction in the dose of one or both medications.
Blood Levels
Blood levels should always be considered in refractory patients to ensure that there is adequate absorption of their current medications and to rule out problems with compliance. Blood levels are not available or helpful for all psychotropic medications.
Blood levels may be particularly helpful for mood stabilizing agents (especially for Lithium, Depakote and Tegretal) and for older tricyclic antidepressants (amitriptyline, nortriptyline, imipramine, desipramine and others).
Correct Diagnosis
Patients with every mental illness are treated based upon a working diagnosis, the diagnosis that best fits their history and current symptoms. Diagnosis is a process that is continuously evolving based upon the development of any new symptoms or new information that becomes available regarding the history of each patient’s symptoms.
Patients who appear to suffer from Schizophrenia may indeed suffer from another diagnosis or a combination of more than one alternative psychiatric diagnosis.
Making a final and accurate determination about the correct diagnosis can be difficult, particularly if patients are experiencing abnormal mood (either in terms of mood quality or mood stability).
Patients who appear to have Schizophrenia, but also demonstrate mood symptoms, may be suffering from Bipolar Affective Disorder, an atypical presentation of Bipolar Disorder, Schizoaffective Disorder or Recurrent Major Depression with Psychotic Features.
The addition of a mood stabilizing agent to antipsychotic medications may only reflect the fact that these drugs are sometimes helpful even when mood symptoms are not apparent, or it may have been added because the patients has demonstrated some indication of an unstable mood.
Substance Abuse
Comorbid substance abuse often complicated the treatment of Schizophrenia. It should always be ruled out or identified and aggressively treated if present.
Nicotine interferes with the metabolism of antipsychotic medications and reduces the effective levels in the blood stream of some antipsychotics.
In recent years, as many inpatient mental health treatment programs have banned smoking, we have found that patients will achieve stability in the hospital, only to develop symptoms again soon after discharge. This may be due to changes in blood levels of their antipsychotic medication when they resume heavy smoking.
When this complication exists we are unable to appropriately adjust doses of antipsychotic medications in the hospital (in the absence of smoking) because patients develop intolerable side effects. The only recourse is to make changes soon after they are discharged. This requires that they are seen for follow-up relatively soon after they leave the hospital.
Psychotherapy
Psychotherapeutic interventions may represent a useful adjunct to medication management for patients with Schizophrenia who continue to experience distressing issues related to their disease or residual symptoms that are resistant to medications.
Family Involvement
The involvement of family members may provide additional support, further assistance in identifying symptoms and medication side effects, as well as critical information about the details of response to treatments and compliance issues.
ACT
ACT (Assertive Community Treatment) has been shown to be an effective alternative to conventional combinations of inpatient and outpatients treatment in refractory patients.
ECT
Electroconvulsive Therapy remains the most effective treatment for patients with unipolar depression and Bipolar Disorder, but can be helpful is select patients with Schizophrenia when other treatments have not been effective.
Clozapine
Clozapine is the only antipsychotic agent that has been approved by the FDA (Food and Drug Administration) for the treatment of refractory Schizophrenia and should always be considered when other medications, or combinations of medications, have failed.
Nutritional Supplements
While nutritional supplements have not been shown to be effective for the treatment of Schizophrenia in double-blind crossover studies, patients and family members report improved symptoms in some instances. They should be discussed with your doctor.
Coping With Persistent Symptoms
Unfortunately, even with the most thorough and aggressive psychopharmacological efforts, some patients with Schizophrenia are forced to endure residual symptoms. In these cases, patients may benefit from efforts to assist them in developing strategies that allow them to recognize disordered thinking and better cope with it.
(Sources: The author’s knowledge base, unless otherwise noted.)
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