Treatment of schizophrenia
In western countries the psychiatrists depend on the precipitating psychological and social events in the treatment of schizophrenic patients but in addition to that they prescribe drugs (neuroleptics) to the patient to enhance quick improvement.On the other hand, the psychiatrists in our country depend mainly on drugs prescription other than discovering or understanding the underlying precipitating factors.
It is very easy to prescribe drugs but it's not hard to understand the patient complaints and feelings.
Now, the treatment of schizophrenia is not by inducing sedation of the patient by the use of drugs. But the purpose of treatments is to treat the psychopathological symptoms of the patient such as (delusions, hallucinations and thought disorders ..etc). Which is usually carried out by the combination of drugs + psychotherapy, industrial therapy, occupational therapy ..etc.
In the acute schizophrenia, it is advised to admit the patient into the hospital followed by taking a complete history of the patient. Then assessment is done for the need of any particular intervention. Inside the hospital, the patient receives two types of therapy physical therapy ex. Drugs and/ or ECT , and non physical therapy such as psychotherapy occupational therapy industrial therapy etc.
Physical therapy:-control excess of dopamine.
Drugs:-the drugs used are called neuroleptics or antipsychotic or ant schizophrenic drugs. They act mainly to control the excess dopamine in certain regions of the brain (mainly the limbic region)
These drugs are classified into typical and atypical drugs. The main drug used is Chlorpromazine (largactil) with its therapeutic antipsychotic effect, tranquillizing effect and sedative effect. If the patient is aggressive and violent Chlorpromazine is used. But in quiet patients, trifluoperazine is preferred rather than Chlorpromazine. It has less sedative effect. However, the Chlorpromazine is used in the acute stage of the schizophrenia in a dose of 100 -200 milligram three times/ day. The dose can be increased but not more than 900 mg per day. The therapeutic effect is expected to appear after the second week of drug intake, onset 10 to 14 days and the drug must be taken for 6-8 weeks after which complete improvement of the patient’s symptoms is expected.
Remission of acute schizophrenic symptoms: maintenance drug course is usually started to prevent relapse of the disorder. The same drug of the acute phase is usually used but with 1/3 -1/2 the dose that had been used in the acute phase. The maintenance period is usually long and continues for about one year. After one year, assessment is done to decide whether to stop or continue the medication. This depends usually on certain factors:-
1-severity of symptoms
2-the response of the family (ie. If the family is high EEF, continuity of drug is preferred, while in low EEF, the drug treatment can be stopped)
3-there are patients who have poor compliance with the drug treatment (ie, they stop the drug treatment) because they think:-
* the drug is a burdensome and sedative.
* they dislike the routine intake of drug treatment.
* the drug is expensive.
* they don't want the schizophrenic symptoms(hallucinations, etc..) to disappear because the sounds that talk or comment with the patient are their only friends.
Rejected cases:-in these cases, it is advisable to use long acting injections of neuroleptics (depot) such as Fluphenazine (decanoate) Fluphenthixol and haloperidol decanoate and others.
Note/these drugs are used in combination with anticholinergic (procyclidines, benzhexol, others) when extrapyramidal side effects appear at any stage of treatment course.
Notes:-
1-the dose of the drug during the 6-8 weeks period can be increased or decreased according to the patients requirement.
2-after about (10-14) days therapeutic effects are expected to appear, but not immediately.
Chronic schizophrenic patients are also treated by neuroleptics (like Chlorpromazine) but the effect of the negative symptoms is usually weak.
Electro Convulsive therapy:- the patient receives electricity(e.g 100 V) for very short period of time. This induces instant loss of consciousness followed by convulsion (grand-mal but epilepsy) in the following steps:-
* Tonic
*Clonic
* Recovery
Nowadays, modification has been achieved of ECT by the use of intravenous anesthesia to prevent the complications of the muscles contractions of the patient at which can lead to a lot of unwanted results for other causes. That is to say intravenous anesthesia + ECT applied
This fit that occurs after the application of ECT is not a side effect. Actually, it is the effect that must occur to be a successful therapy. The ECT has indications to be used which are:-
1-in catatonic behavior in which the patient refuses to eat and drink and this leads to the number of medical emergencies.
2-it is the second line treatment after failure of drug therapy.
3-in postnatal psychosis.
4-in depression the schizophrenic patients have suicidal attempts than 10% of cases due to severe depression that may associate with it.
5-cases where primary treatment was not effective very well (i.e. No significant improvements)
In addition to that, ECT has also contraindications: (ex organic psychosis, etc..) and many side effects that are sometimes harmful to the patient
After demonstration of drugs and ECT of a subdivision of physical therapy we will deal with other types of treatment.
Non physical therapy:-
Here we try to strengthen the patient ties with reality and try also to increase the self confidence of the patient. This purpose is usually reached by the application of “rehabilitation" that is one of the most important treatment in psychiatry. It starts with the first day of the patient’s admission the hospital with the drug therapy.
Rehabilitation helps the patient to know how to care , drink, eat and others so that the patient returns as one of members of the society with an acceptable behavior.
A/occupational therapy:-
Here in patients learn either a new job or refurbish old one/ i.e. either acquiring a new skill or continue on the same or old one. There are a number of examples -- Sewing, carpet making, or working as a smith or carpenter. It has been found that the occupational therapy calms the anxious patients and affords some degree of satisfaction for all patients.
Occupational therapy prevents worsening of patient’s state and has a role in remission. Here the patient avoids the boring routine day life because he needs a balanced environment. If there is high stimulation relapse may occur and if the day life passes without events the chronicity will be established. So the patient is in need to a suitable environment where no high stimulation nor routine day life and neglect are present.
B/psychotherapy:-supportive and analytic
There are two types of psychotherapy which are the supportive and analytic psychotherapy. In addition there are individual and group psychotherapy.
However the schizophrenic patients are treated by supportive psychotherapy in which the patient is encouraged to talk freely about himself and the symptoms and problems without exploring his unconscious mental life. On the other hand the psychiatrist must give attention to the patient and listen carefully. The psychiatrist or any other member of the psychiatric medical staff can add possible solution of the patient’s problems in a gentle manner.
C/Family therapy:-here we have to teach the members of the family to be merciful with the patient and to avoid committing continuously on his behavior. They must also give attention to the presence of the patient as a human being who may carry thoughts as are of benefits in solving certain problems.. ect..
D/Community therapy:- The patient is admitted into the hospital for a long time during which the patient is exposed to a new environment. It's advisable to make free communication between the patient and the psychiatrist medical staff, thus removing meaningless barriers between them. In addition the patients need activity and hope so that they can adapt quickly to the hospital environment.
E/Behavior therapy:-this term is applied to a variety of psychiatric treatment in which the patients are re-educated freely from abnormal behavior.
There are several methods of behavior therapy:-
1-over practice: here the patient is entered into a large in which a lot of blankets, pillows and carpets are present. The patients who has a desire to arrange these things continuously will lose this desire to do the presence of these thing in high number.
2- Positive reinforcement: here the patient is given a gift or money when he carries out a desired dust or behavior.
F/industrial therapy:-here certain jobs are provided for schizophrenic patients especially in the chronic cases. In fact, the type of work chosen for them must be suitable and associated with encouragement and supervision.
Notes/the jobs are usually practiced outside the hospital (for example : factories...)
Then after the application of these therapies, a patient is shifted a day hospital in which patient spent several hours during the day without remaining in it during the night.
Here the patient eats, learns music, and do other activities and hobbies. This hospital is a transient stage between the hospital and the community to which the patient will return of the normal member of it with acceptable behavior.
Note/treatment of schizophrenia is difficult and hard and needs corporation and patience of both the doctor and the patients.
After demonstration the lines of treatments of schizophrenia we will deal with the antipsychotic drugs (neuroleptics) and their classification.
The antipsychotic drugs:-
The drugs are classified into typical and atypical according to the mechanism of action:-
1-Typical antipsychotic drugs:-
A/Phenothiazines 1-chlorpromazine (largectil) 2-Thioridazine 3-Trifluperazine 4-Fluphenazine decanoate 5-Fluperazine 6-Fluphenazine ethanol 7-Perphenazine 8-Mesonidazine 9-Acetophenazine maleate 10-Fluphenazine hydrochloride 11-Prochlorperazine.
B/Butyrophenones 1- Haloperdol 2- Droperidol 3-Haloperidol decanoate
C/Thioxanthenes 1-Flupenthixol 2-Clopenthixol 3-Zuclopenthixol
D/Diphenylbutylpiperidine Pimozide
E/Dibenzoxazines Loxapine succinate
F/Indole derivatives molindone hydrochloride
Side Effects:-
Sedation, Extra pyramidal symptoms , HYPERLINK "http://en.wikipedia.org/wiki/Akathisia" \o "Akathisia" akathisia, parkinsonism, HYPERLINK "http://en.wikipedia.org/wiki/Dystonia" \o "Dystonia"dystonias ,Malignant neuroleptic symptoms , metabolic side effects ,increased weight (anticholinergic)
2- Atypical Antipsychotic drugs :-
A/Benzisoxazoles 1- Risperidone 2- Zeprasidone
B/Dibenzodiazepines 1-Clozapine 2- quetiapine fumarate
C/Thiolbenzodiazepines Olanzapine