Schizoaffective Disorder
Medical Treatment for Schizoaffective Disorder
Antipsychotic Drugs for Treating Schizoaffective Disorder
Antipsychotic medications are the treatment of choice. Evidence to date
suggests that all of the
antipsychotic drugs (except clozapine) are
similarly effective in treating psychoses, with the differences being in
milligram potency and side effects.
Clozapine (Clozaril) has been proven to
be more effective than all other antipsychotic drugs, but its serious
side-effects limit its use.
Individual patients may respond to one drug better than another, and a
history of a favorable response to treatment with a given drug in either the
patient or a family member should lead to use of that particular drug as the
drug of first choice. If the initial choice is not effective in 2-4 weeks,
it is reasonable to try another antipsychotic drug with a different chemical
structure.
Often an agitated, psychotic patient can be calmed in 1-2 days on
antipsychotic drugs. Usually the psychosis gradually resolves only after 2-6
weeks of a high-dose antipsychotic drug regimen. A common error is to
dramatically reduce antipsychotic drug dosage just as the patient improves
or leaves hospital. This error almost guarantees a relapse. Major reduction
in antipsychotic drug dosage should be avoided for at least 3-6 months after
hospital discharge. Decreases in antipsychotic drug dosage should be done
gradually. It takes at least 2 weeks for the body to reach a new equilibrium
in antipsychotic drug level after a dose reduction.
Sometimes patients view the side-effects of the antipsychotic drugs as
being worse than their original psychosis. Thus clinicians must be skillful
in preventing these
side-effects. Sometimes these side-effects can be
removed by simply reducing the patient's antipsychotic drug dosage.
Unfortunately, such reduction in drug dosage often causes patients to
relapse back into psychosis. Therefore clinicians have no choice but to use
the following treatments for these antipsychotic side-effects:
Acute Dystonic Reactions: These reactions are of abrupt onset,
sometimes bizarre, frightening muscular spasms mainly affecting the
musculature of the head and neck. Sometimes the eyes go into spasm and
roll back into the head. Such reactions usually take place within the
first 24 to 48 hours after therapy has begun or, in a small number of
cases, when dosage is increased. Males are more vulnerable to the
reactions than females, and the young more so than the elderly. High
doses are more likely to produce such effects. Although these reactions
respond dramatically to the intramuscular injection of antihistamines or
anti-parkinson agents, they are frightening and are best avoided by
starting with lower antipsychotic drug dosages. Anti-parkinsonian drugs
(e.g., benztropine, procyclidine) should be prescribed whenever
antipsychotic drugs are started. Usually these anti-parkinsonian drugs
can be safely stopped in 1-3 months. Akathisia: Akathisia is experienced as an inability to sit or stand
still, with a subjective feeling of anxiety. Beta-adrenergic antagonists
(e.g., atenolol, propranolol) are the most effective treatment for
akathisia. These beta-blockers usually can be safely stopped in 1-3
months. Akathisia may also respond benzodiazepines (e.g., clonazepam,
lorazepam), or to anti-parkinson drugs (e.g., benztropine, procyclidine). Parkinsonism: Akinesia, a key feature of parkinsonism, may be
overlooked, but if the patient is asked to walk briskly for some 20
paces, diminution of the swing of the arms can be noted, as can loss of
facial expression. These parkinsonian side-effects of antipsychotic
drugs usually respond to the addition of an anti-parkinson drug (e.g.,
benztropine, procyclidine). Tardive Dyskinesia: Between 10 to 20 percent of patients receiving
antipsychotic agents develop some degree of tardive dyskinesia. It is
now known that many cases of tardive dyskinesia are reversible and that
many cases do not progress. Early signs of tardive dyskinesia are mostly
seen in the area of the face. Movements of the tongue inside the buccal
cavity that consist of retraction of the tongue on its longitudinal axis
or irregular rotation around the longitudinal axis, with frequent
movements in lateral directions, are thought to be the earliest signs.
Choreoathetoid movement of the fingers and toes may also be observed, as
may respiratory dyskinesia associated with irregular breathing and,
perhaps, grunting.
Tardive dyskinesia is thought to result from dopamine receptor
supersensitivity following chronic receptor blockade by the
antipsychotic agent. Anticholinergic drugs do not improve tardive
dyskinesia and may make it worse. The recommended treatment of tardive
dyskinesia is to lower the dosage of antipsychotic drugs and hope for
gradual remission of the choreoathetoid movements. Increasing the dosage
of an antipsychotic briefly masks the symptoms of tardive dyskinesia,
but symptoms will reappear later as a reflection of the progression of
receptor supersensitivity. Neuroleptic Malignant Syndrome: Antipsychotic agents potentiate
anticholinergic drugs, and toxic psychosis may occur. This confusional
state usually appears early in treatment and, more commonly, at night
and in elderly patients. Withdrawal of the offending agents is the
treatment of choice. Antipsychotic drugs often interfere with body
temperature regulation. Therefore, in hot climates this situation may
result in hyperthermia and in cold climates hypothermia.
The neuroleptic malignant syndrome is an exceedingly rare but
potentially fatal condition characterized by parkinsonian-type rigidity,
increased temperature, and altered consciousness. The syndrome is
ill-defined and overlaps with hyperpyrexia, parkinsonism, and
neuroleptic-induced catatonia. Coma may develop and result in rare
terminal deaths. This syndrome is reported most often in young males,
may appear suddenly, and usually lasts 5 to 10 days after cessation of
neuroleptics. There is no treatment; therefore, early recognition and
discontinuation of antipsychotic drugs, followed by supportive therapy,
are indicated. Hypersomnia And Lethary: Many patients on antipsychotic drugs sleep
12-14 hours per day and develop marked lethary. Often these side-effects
disappear when treated with the newer serotonergic antidepressants
(e.g., fluoxetine, trazodone). These antidepressants usually are given
for 6 or more months. Other Side-Effects: Depressed S-T segments, flattened T-waves,
U-waves, and prolonged Q-T intervals may be caused by antipsychotic
drugs. This situation is cause for concern, is more liable to occur with
low potency agents, particularly
thioridazine, and could increase
vulnerability to arrhythmia.
It is not possible to say to what extent antipsychotic drugs are
involved in sudden death. Serious reactions to antipsychotic drugs are
rare. Photosensitivity reactions are most common with chlorpromazine;
vulnerable patients should wear protective screens on their exposed
skin.
Pigmentary retinopathy is associated with thioridazine and may impair
vision if not detected. This complication occurred at dosages below the
considered safe limit of 800 mg. Dosages of above 800 mg are, therefore,
not recommended.
Antipsychotic agents may affect libido and may produce difficulty in
achieving and maintaining erection. Inability to reach orgasm or
ejaculation and retrograde ejaculation have been reported.
Antipsychotics also may cause amenorrhea, lactation, hirsutism, and
gynecomastia.
Weight gain may be more liable to occur with any antipsychotic drug
which causes hypersomnia and lethargy. Onset of
diabetes is another problem associated with atypical antipsychotics.
Studies suggest that many
antipsychotic drugs taken during pregnancy do not result in fetal
abnormalities. Because these agents reach the fetal circulation, they
may affect the newborn, thus producing postnatal depression and also dystonic symptoms.
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