Antipsychotic drugs
Antipsychotic drugs are medicines used to treat psychosis and other mental and emotional conditions. Psychosis is a severe mental illness in which peoplelose touch with reality. They may hear voices, see things that aren't reallythere, and have strange or untrue thoughts, such as believing that other people can hear their thoughts or are trying to harm them. They may also neglecttheir appearance and may stop talking or talk only "nonsense."
Antipsychotic drugs do not cure mental illness but can reduce some of the symptoms or make them milder. The medicine may improve symptoms enough for the person to undergo counseling and live a more normal life. The type of antipsychotic medicine prescribed depends on the type of mental problem the patient has. There are two main classifications of psychosis; the first is organic brain syndrome, a temporary or permanent structural dysfunction of the brain with symptoms such as confusion and anxiety. The second classification of psychosis includes the conditions schizophrenia and bipolar disorder (manic depression). These illnesses are thought to be the result of a combination of biological and environmental factors. Patients with organic brain syndrome, schizophrenia and bipolar disorder can experience psychosis when their illness is inan extreme state, but antipsychotic drugs can minimize or even eliminate theeffects of psychosis.
Until the 1950s, the only treatment available for patients who were prone topsychotic episodes was long-term hospitalization. When Thorazine entered theUnited States market in 1952 for treatment of schizophrenia, many psychiatricinpatients were able to receive treatment on an outpatient basis and live ina much less restrictive environment. Other "first generation" antipsychoticmedications entered the market and while they gave patients with psychosis many new options, there were still drawbacks because severe side effects were quite common.
First generation antipsychotic drugs include Haldol, Thorazine, Mellaril, Prolixin and Navane. They are thought to work by blocking the effect of certaindopamine receptors (chemicals) in the central nervous system. The medical process is still not fully understood, but when particular dopamine receptors are suppressed in a patient with a tendency toward psychosis, usually the patient will experience a reduction of symptoms such as hallucinations and delusions. Other effects of psychosis, such as emotional withdrawal, do not seem tobe helped by first generation antipsychotic drugs.
Most patients with bipolar disorder tolerate and respond to lithium, a treatment that was clinically proven in the 1960s. Lithium is a close chemical cousin to common table salt. It is an element that exists in nature, so it is notin the same category as first generation antipsychotic drugs that were formulated in a laboratory.
Antipsychotic medicines are available only with a physician's prescription. The recommended dosage depends on the type of drug, the condition for which itis prescribed, and other factors. Patients are cautioned to take antipsychotic drugs exactly as directed, never in larger or more frequent doses, and never for longer than directed. This is important for all patients, but especially for older people and children, who may be more sensitive to this type of medicine. Patients are cautioned not to stop taking the medicine, as withdrawal symptoms can be dangerous.
Antipsychotic drugs may interact with medicines used during surgery, dental procedures, or emergency treatment. These interactions could increase the chance of side effects, so it is important that health care professionals be notified. Some antipsychotic drugs may change the results of certain medical tests so again, the appropriate health care professional should be notified.
Some people feel drowsy, dizzy, or less alert when using these drugs, especially as doses increase. Antipsychotic drugs may also cause blurred vision andother vision changes and may affect judgment. Because of these possible problems, anyone who takes these drugs should not drive, use machines or do anything else that might be dangerous until they have found out how the drugs affect them. The drugs may increase sensitivity to sunlight. Even brief exposure to sun can cause a severe sunburn or a rash. Hence appropriate precautions need to be taken.
People taking antipsychotic medicines may sweat less, which can cause the body temperature to rise. Anyone who takes this medicine should be careful not to become overheated during exercise or hot weather and should avoid hot baths, hot tubs, and saunas. Overheating could lead to heat stroke. Some antipsychotic drugs make people more sensitive to cold. Anyone who takes this medicineshould dress warmly in cold weather and take care to avoid long exposure tothe cold.
Children may be especially sensitive to the effects of antipsychotic drugs. This sensitivity may increase the chance of side effects, especially muscle spasms and involuntary movements. Lithium may weaken the bones of children whotake it.
People with certain medical conditions or who are taking certain other medicines can have problems if they take antipsychotic drugs, so the prescribing physician will need to be informed of all other medical conditions. Anyone whohas had unusual reactions to antipsychotic drugs in the past should let his or her physician know before taking the drugs again. The physician should alsobe told about any allergies to foods, dyes, preservatives, or other substances.
Women who are pregnant or who may become pregnant should check with their physicians before using antipsychotic drugs. Some antipsychotic drugs pass intobreast milk and may cause drowsiness and other problems in nursing babies whose mothers use the drugs. Breastfeeding is not recommended during treatment with antipsychotic drugs.
Some of the side effects of antipsychotic drugs will go away as the patient'sbody adjusts to the medicine and do not need medical attention unless they continue or they interfere with normal activities. If more serious side effects occur, the physician should be contacted immediately.
Antipsychotic drugs may interact with a number of other medicines. When thishappens, the effects of one or both of the drugs may change or the risk of side effects may be greater. Because antipsychotic drugs work on the central nervous system, they may add to the effects of alcohol and other drugs that slow down the central nervous system.
The most common side effects of traditional antipsychotic drugs are neurologic and can include muscle spasms of the tongue, face, jaw, neck, back, larynxor eyes. The reactions can be painful and even life-threatening if they affect the patient's airway. Drugs such as Cogentin, Benadryl and Ativan help in counteracting these side effects.
Patients on traditional antipsychotic drugs can also experience pseudoparkinsonism, a condition that mimics the symptoms of Parkinson's disease. The patient may develop a shuffling gait, tremors, rigid muscles or a decrease in spontaneous movement. The pseudoparkinsonism effect is more common in patients onhigh doses and is more likely to affect older women. The side effects usually respond to Symmetrel.
Patients who experience side effects such as anxiety and motor restlessness present clinicians with a more complicated problem, because it is sometimes difficult to figure out whether the behavior is a pharmaceutical side effect ora symptom of psychosis. Often the patient will rock back and forth in a chair, pace the floor and be too agitated to sit still. If the patient worsens when given a higher dose of the drug, then the dose should be decreased and administration of a beta blocker such as Inderal or lorazepam will help controlthe side effects.
Older patients and patients on high doses of traditional antipsychotic drugsare at risk for tardive dyskinesia. This syndrome includes side effects suchas facial grimacing, tics, writhing of the tongue, and abnormal movements ofthe lips, neck, trunk and limbs. There are no proven treatments for tardive dyskinesia and the symptoms can be irreversible.
Many patients experience weight gain on traditional antipsychotic drugs, withthe average patient gaining between 3 and 9 pounds. Other less common side effects include seizures, sensitivity to light, jaundice (a liver condition),and increased secretion of prolactin, which can cause enlarged breasts in both men and women. Prolactin can cause impotence and men and an absence of menstrual bleeding in women.
A few studies performed in the 1990s suggest that traditional antipsychotic agents might even contribute to such the long-term symptoms as emotional withdrawal and a blunting of the patient's ability to express emotion.
Faced with these numerous potential side effects, many patients on traditional antipsychotic drugs find it difficult to tolerate their medication and theystop taking it. Some patients who are helped by antipsychotic drugs cannot be persuaded to continue taking the drugs when they are feeling well. The American Psychiatric Association estimates that 50% of schizophrenic patients stop taking their medication within six months of discharge because of troublesome side effects such as muscle spasms, restlessness and tremors. Statistics gathered at Oregon Health Sciences University show that 52% of schizophrenic patients are readmitted within a year of hospital discharge, and this figure applies only to patients with no previous history of readmission. Statistics worsen with each cycle of discharge and readmission. One study placed the relapse rate for schizophrenic patients who were noncompliant with medication at76% within one year.
Ironically, some of the successes of antipsychotic medications may have contributed to economic trends in psychiatry that are unfavorable to patient care.There are few state-supported inpatient mental hospitals at the end of the twentieth century. For example, the most populous state, California, has onlyone state mental hospital. At a symposium on trends in psychiatry, researchers pointed out that most psychiatric patients do not receive long-term inpatient therapy. Such therapy was only thought to be necessary prior to the era ofantipsychotic medication and is now in very short supply. Costs have been shifted so patients are treated in short-stay general hospitals, with federal funds increasingly picking up the tab. Critics refer to this pattern as a revolving door. Statistics presented at the same symposium show that "revolving door" care for relapsed patients in the United States cost $2.3 billion in 1993.
Mental health professionals hope the new generation of "atypical" antipsychotic drugs will encourage greater compliance, because new formulations have minimized the most troublesome side effects. The "second generation" antipsychotics, introduced in the mid-1990s, include Risperdal, Seroquel, Zyprexa and Zeldox. While the cost per dose is much higher than for traditional antipsychotic medicines, preliminary studies show the relapse rate is much lower, because patients are able to tolerate the drugs. With many of the hospital readmission costs eliminated, the expenses for overall care are reduced. Switching apatient from traditional antipsychotic medication to atypical antipsychotic medication takes careful management. Usually the treating physician will overlap the drugs over a short period, gradually tapering the dose of the traditional drug. The patient may experience withdrawal symptoms as the traditional drug dose is reduced. Clinicians recommend overlapping the drugs for a periodno longer than one or two weeks to minimize the time the patient is on both drugs.
While many patients are good candidates to try atypical antipsychotic drug therapy, not all patients should proceed. Good candidates are patients who havebeen stable for at least three to six months on their current therapy. Patients who would be a risk to themselves or to others if their symptoms worsenedshould not attempt the switch. Patients who hesitate to change medications should not be pressured to do so. The atypical antipsychotic drugs are available only by mouth, so patients who are receiving therapy by injection are notcandidates. If a patient is in relapse or has been rehospitalized, a switch to atypical drugs can be attempted if close monitoring is available. The patients most likely to benefit from a switch to second generation antipsychotic drugs are those who have had persistent side effects even when compliant withfirst generation therapy. Clinicians recommend continuous patient education and support to convince patients of the importance of taking antipsychotic medication even when they are feeling well.
Although the atypical antipsychotic medicines offer hope to many patients, the National Mental Health Association (NMHA) points out that the medicines themselves must be used in a supportive environment to be effective. Neither traditional nor atypical antipsychotic drugs were being used optimally, according to a survey published in 1999. A random survey of schizophrenic patients showed that 38% received inadequate medication management and 52% received inadequate psychosocial care. More information on the NMHA's campaign to raise public awareness about treatment options for mental illness is available at 800-969-NMHA or http://www.nmha.org.
The American Psychiatric Association (APA) reports that 5% to 25% of schizophrenic patients are partially or totally unresponsive to any form of antipsychotic medication. The APA does not recommend treating a patient with more thanone antipsychotic drug at a time, but there are a few early reports of success in using two antipsychotic drugs on selected patients. Electroconvulsive shock therapy (ECT) is sometimes tried on patients who do not respond to drugtherapy.
New trends in psychiatric health care have affected the multinational pharmaceutical companies that develop and market antipsychotic medications. A comparison of the cost of atypical antipsychotic drugs (and some new antidepressants) in the United States with the cost of the same drugs in Europe showed thaton average, each drug costs twice as much in the United States. The Europeancountries all had national health insurance which allowed each country to negotiate drug prices. The United States pharmaceutical industry says its charges are based on the costs of research and development of new drugs. Critics have examined the costs of two popular second generation antipsychotic drugs,Risperdal and Clozaril, which were developed in Europe. The pattern of charging twice as much in the United States as in Europe seems to hold, no matter where the drug was actually developed.
Four multinational pharmaceutical companies stopped supplying Pakistan with atypical antipsychotic drugs in March 1999. The companies are demanding priceincreases that Pakistan has refused to pay. Each time the companies try to raise prices and Pakistan resists, the companies cut the drug supply, includingantipsychotic drugs, a violation of the 1976 Drug Act. Thousands of Pakistani patients with psychiatric disorders are at risk, as Pakistan does not havesufficient resources to hospitalize patients who were previously stable on antipsychotic medications. There is additional risk that untreated patients maypose a danger to themselves and others. Pakistan is encouraging its own pharmaceutical companies to try to manufacture the antipsychotic drugs and avertthe crisis. In the meantime, some patients' only recourse is to look for black market antipsychotic drugs at inflated prices.
In the mid-1990s, the pharmaceutical industry began marketing mental health drugs directly to consumers. Eli Lilly &Company, makers of the antipsychotic Zyprexa, is offering scholarships to some patients who are taking Zyprexa.Lilly says the scholarships are intended to help schizophrenics live normallives by taking classes at college or professional school. Some manufacturersof second generation antipsychotic drugs are looking for ways to gather patient names and other information that could be used for marketing to people with mental health problems. Some companies, like Janssen Pharmaceutica, invitepatients to visit its web site and register to receive information updates.Physicians surveyed in 1996 had a 51% negative opinion of direct-to-consumerdrug marketing.