General principles of psychopharmacotherapy
Antipsychotics, like most similar agents, do not affect the underlying cause of the disease and are not able to lead to a complete recovery on their own. Their main target is specific syndromes.
- Comprehensive approach. The treatment outcome largely depends on eliminating etiological factors.
- Persistence of effect. Despite their strictly syndromal action, the clinical effect of neuroleptics can be very persistent. This allows for long-term restoration of patient adaptation, and in chronic psychiatric diseases, for long-term condition control, maintaining working capacity, and preventing relapses.
Indications for use
The range of neuroleptic applications covers not only severe mental disorders, but also somatic problems.
- Psychoses and schizophrenia: relief of positive symptoms (delusions, hallucinations, catatonia), pronounced psychomotor agitation, and associated insomnia. The drugs also work effectively against the negative symptoms of schizophrenia.
- Behavioral and thought disorders: neuroleptics are indicated for active suicidal ideation, tendencies toward acute conflicts, impulsivity, and general unmanageability. In neuroses and psychopathies, they relieve obsessions and overvalued ideas.
- Mood swings: used in bipolar disorder and to suppress bursts of aggression.
- Somatic medicine: the drugs are prescribed to relieve intractable vomiting, skin pruritus, and as an adjunct in the treatment of peptic ulcer disease, arterial hypertension, hyperthyroidism, and bronchial asthma. They are indispensable in preparation for surgeries, chemotherapy, and radiation therapy, significantly improving the patient's quality of life.
Dosage and duration of therapy
The therapeutic range of neuroleptics is wide: the therapeutic effect can be achieved from both minimal (a quarter of a tablet) and high doses (up to 10–15 tablets per day). Dosage is selected strictly individually.
- Dose-dependent effect. Low and high doses of the same drug can work in opposite ways: low doses produce a sedative effect, while high doses produce a disinhibiting (activating) effect.
- Prolonged-release forms. For passive patients who forget to take their medications, depot preparations are used (haloperidol decanoate, moditen depot, risperdal consta). They are administered infrequently and act for a week or longer.
- Short-acting drugs. Such agents (e.g., droperidol, which works for 2–3 hours) are optimal for the rapid relief of acute psychosis, but require frequent administration (3–5 times a day).
Age-related features and combinations
The prescription of neuroleptics requires special attention to the patient's age and concomitant therapy.
- In pediatrics: the drugs are recognized as highly effective and safe in the treatment of early childhood schizophrenia and autism. Their administration prevents intellectual delay and helps the normal development of the child. The dose is calculated per kilogram of body weight or by body surface area.
- In the elderly: geriatric patients tolerate neuroleptics much better than tranquilizers (which cause severe myorelaxation and falls). However, long-acting antipsychotics (levomepromazine) are strictly not recommended for the elderly due to slowed metabolism and a high risk of accumulation.
- Combination: although monotherapy is preferred in psychiatry, there are rational combinations to enhance the effect. Neuroleptics are reasonably combined with antidepressants or with the side-effect corrector trihexyphenidyl (cyclodol).
Briefly: answers to topical questions
What extrapyramidal side effects does the intake of typical neuroleptics cause?
- Acute dystonia — painful spasms of the face, neck, tongue, eyes, pharynx, larynx, occurring on the 2nd–5th day of treatment.
- Parkinsonism — tremor, general muscle hypertonia, amimia, and shuffling gait.
- Akathisia and tasikinesia — restlessness, the urge to move constantly, and motor agitation.
- Tardive dyskinesia — persistent facial hyperkinesias, as well as choreiform and athetoid movements in the limbs.
The intake of typical antipsychotics provokes pronounced neurological disorders of the extrapyramidal system. These include acute painful muscle spasms, drug-induced parkinsonism with muscle rigidity and tremor, akathisia with an irresistible urge to move, and tardive dyskinesia in the form of persistent hyperkinesias.
The rule of three "Ps" will help remember the profile of antipsychotics: they treat Psychoses (delusions, hallucinations), Behavior (aggression, suicide), and Psychosomatics (vomiting, ulcer, pruritus).
Class and exam questions
Do antipsychotics cause drug addiction?
No, the risk of developing substance abuse or drug addiction when taking neuroleptics is extremely low. Unlike psychostimulants or tranquilizers, they do not cause pathological craving.
When does the effect of neuroleptics appear?
Their therapeutic effect is delayed. A significant clinical effect appears by the end of the second or third week of therapy, which is important to warn the patient about in advance.
How to treat patients who forget or refuse to take pills?
In such cases, prolonged-release depot preparations (e.g., haloperidol decanoate) are prescribed. They are administered by injection, and their effect persists for a long time.
What else to study on this topic
- Types of therapy in psychiatry: abortive, maintenance, and corrective
- Shock treatment methods (ECT and insulin coma therapy)
- Use of antidepressants and mood stabilizers
- Peculiarities of prescribing tranquilizers in the elderly: risk of falls
- Pharmacokinetics of psychotropic drugs and the problem of accumulation
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Other topics in "Chapter 17. Therapy of Mental Disorders. Basic Principles of Prevention and Rehabilitation"
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