Antidepressants. Patients with schizophrenia can develop depression, even if they do not meet diagnostic criteria for schizoaffective disorder. Untreated depression can lead to non-adherence, self-medication with alcohol or illicit substances, and increased risk of suicide.
Differentiating depression from negative symptoms may be difficult, but there are subtle distinctions:
- Patients with negative symptoms appear more emotionally flat and unconcerned about their lack of motivation and diminished social and role functioning.
- Depressed persons often verbalize their demoralization, hopelessness, and desire to feel and behave differently.
Treat depression with any selective serotonin reuptake inhibitor or other newer-generation antidepressant such as mirtazapine, nefazodone, or venlafaxine at usual doses, as tolerated.
Miscellaneous medications. Use anticholinergic medications such as benztropine, 0.5 to 2 mg bid, or trihexyphenidyl, 1 to 5 mg bid, if parkinsonian symptoms occur and changing to an antipsychotic with a lower EPS potential is not feasible.
For akathisia, propranolol (10 mg bid or tid; titrate up to 160 mg/d if pulse rate and blood pressure remain stable) or benzodiazepines may be useful. Amantadine may also be used at dosages between 50 and 150 mg bid.
Insomnia may be treated with low dosages of sedating antidepressants, such as trazodone, 50 to 200 mg HS, or mirtazapine, 7.5 to 15 mg HS.
Preventing relapse during maintenance
Medication adherence depends on patient insight and attitude towards medications.23 Once you start a first-episode patient on drug therapy, encourage adherence by monitoring symptoms and anticipating side effects. Every 3 months after the acute phase:
- Use a structured evaluation, such as the Brief Psychiatric Rating Scale,24 to plot symptom severity, response, and risk for relapse.
- Rate EPS with the Simpson-Angus Scale25 and tardive dyskinesia (TD) with the Abnormal Involuntary Movement Scale26 because EPS and TD are associated with poor symptom response, adherence, and outcome.7
Reinforce information about the chronic nature of schizophrenia, especially when the patient or family question why treatment is needed if symptoms have resolved. Continue to counsel them about the patient’s need for:
- regular sleep of sufficient duration and without sleep-wake reversal
- gradual return to premorbid social, educational, and vocational activities/responsibilities
- ongoing treatment.
Encourage vigilance for relapse warning signs, including insomnia, social withdrawal, anxiety, refusal to eat or take medications, suspiciousness, agitation, disorganization, preoccupation with overvalued ideas, or responses to internal stimuli.
If the patient is noncompliant with antipsychotics in tablets or capsules, options include:
- liquid risperidone or olanzapine in a rapidly dissolving form that the patient cannot hide and spit out later
- long-acting depot formulations if the patient cannot be supervised and monitored daily. Older antipsychotics (such as haloperidol decanoate and fluphenazine decanoate) are available in depot formulations, and the FDA is considering risperidone in a microsphere formulation that would allow biweekly injections.
Medication withdrawal
Although the ideal duration of maintenance treatment after a first psychotic episode is debatable, we recommend that antipsychotics be continued at the full dosage that achieved symptom remission for at least 1 year.27 Then, if the patient has returned to the premorbid baseline, you can attempt a gradual medication withdrawal across 2 to 4 months, ideally when the patient’s environment is stable.
Be cautious when withdrawing antipsychotics from patients with a family history of psychosis. Consider a more gradual dose reduction, ongoing group and/or individual psychotherapy, and at least monthly monitoring. When possible, involve people who are significant in the patient’s life and educate them to look for deterioration’s warning signs, such as insomnia, irritability, anxiety, social withdrawal, preoccupation with overvalued ideas, or pacing.
If relapse occurs, carefully assess how well the patient has adhered to medication. Once a second psychotic episode occurs, his or her medication probably should be continued indefinitely.
- National Alliance for the Mentally Ill (800) 950-NAMI (6264); www.nami.org
- National Mental Health Association (800) 969-NMHA (6642); www.nmha.org
- National Alliance for Research on Schizophrenia and Depression (516) 829-0091; www.narsad.org/index.html
- Miller R, Mason SE. Diagnosis schizophrenia. A comprehensive resource. New York: Columbia University Press, 2002.
Drug brand names
- Aripiprazole • Abilify
- Bupropion • Wellbutrin
- Citalopram • Celexa
- Clozapine • Clozaril
- Escitalopram • Lexapro
- Fluoxetine • Prozac
- Fluvoxamine • Luvox
- Gabapentin • Neurontin
- Lamotrigine • Lamictal
- Lorazepam • Ativan
- Mirtazapine • Remeron
- Nefazodone • Serzone
- Olanzapine • Zyprexa
- Paroxetine • Paxil
- Quetiapine • Seroquel
- Risperidone • Risperdal
- Sertraline • Zoloft
- Trazodone • Desyrel
- Venlafaxine • Effexor
- Ziprasidone • Geodon
- Zolpidem • Ambien
Disclosure
Dr. Correll reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Dr. Mendelowitz receives grant/research support from, is a consultant to, and/or is a speaker for Pfizer Inc., Bristol-Myers Squibb Co.; and AstraZeneca Pharmaceuticals.
Acknowledgments
Research for this article was supported by grant 5P30MH60575 to The Zucker Hillside Hospital Intervention Research Center for Schizophrenia from the National Institute of Mental Health, Bethesda, MD.