Module 4 - Schizophrenia and Other Psychoses

The Management of Schizophrenia


The first line treatment for psychotic disorders is antipsychotic medication. Please note that Module 10 deals with medication in more detail. Treatment with antipsychotic medication can have almost immediate benefits in reducing arousal, agitation, aggression and distress. The core psychotic symptoms only improve after four to six days of treatment with regular antipsychotic medication. During this time sedative and hypnotic medications can be utilised, in addition to antipsychotic medication, to reduce the behavioural disturbance (and therefore reduce risk), calm the person and improve their sleep. It may be several months before symptoms resolve more completely and in some people they continue at a less intense level. The effective dose of antipsychotic medication varies for each individual and side effects are common and may limit treatment. If a person has been unable to tolerate or has failed to respond to treatment Clozapine may be recommended which can be very effective but can have significant side effects and means the person has to have regular blood tests.  However it is important to be certain that the person has been regularly taking their medication before deciding the illness is resistant to treatment. If the person has not been taking their medication regularly then it may be necessary to treat the person with other preparations of antipsychotic medications such as rapidly dissolving tablets, liquids or injections. Once a person is stable on medication the treatment should continue for at least 2 years, although at the minimum effective dose which may be less than the dose required fo acute treatment. This minimises the risk of relapse when the medication is stopped. However, some people require long term treatment with antipsychotic medication. This is required if there has only been a partial response to treatment, if the symptoms are continuous or if there are frequent relapses when medication is reduced or discontinued. Non-compliance with medication is common. The reasons for this include the fact that antipsychotic medications have a number of side effects (tremor, for example), and individuals may feel stigmatised, inconvenienced or limited by having to take medication. Others will have poor insight in to their illness and believe that they have never been unwell and do not need medication However, ideally antipsychotic medication should not be abruptly stopped and it is preferable that the dose is gradually reduced. There should be regular psychiatric review during this time to ensure that symptoms of relapse are identified early. A significant number of people will relapse when medication is reduced or discontinued, requiring recommencement of medication The treatment of negative symptoms also differs from the treatment of acute episodes and negative symptoms can be difficult to treat. Mood stabilising medication or antidepressants may be prescribed in schizoaffective disorder or if there is a strong mood component to a person’s presentation. It is common for people to become depressed after an acute psychotic episode and it is important to recognise this, exclude negative symptoms and provide appropriate treatment.
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