Main therapy: antipsychotics
Pharmacotherapy is the cornerstone of schizophrenia treatment, with a primary emphasis on antipsychotics. The choice of a specific drug depends on the predominant symptoms:
- Psychomotor agitation and confusion: chlorpromazine, clozapine, chlorprothixene, zuclopenthixol, and olanzapine are used.
- Delusions and catatonic disorders: haloperidol, risperidone, trifluoperazine, perphenazine, fluphenazine, and olanzapine are indicated.
- Negative symptoms (autism, passivity): atypical antipsychotics are used, such as clozapine, aripiprazole, risperidone, olanzapine, flupenthixol, sulpiride, amisulpride, and ziprasidone. Their continuous administration helps the patient maintain social skills.
- For long-term maintenance: long-acting injectable formulations (depot forms) are convenient—moditen depot, haloperidol decanoate, clopixol depot.
Principles of therapy and side effect management
The gold standard is monotherapy—prescribing only one antipsychotic. However, if the patient tolerates the drug poorly, the physician may combine two medications to lower doses, reduce side effects, or make the treatment more cost-effective.
Typical antipsychotics can cause neurological disorders, which are treated with anticholinergic agents (e.g., trihexyphenidyl, biperiden, diphenhydramine).
Additionally, the following may be prescribed to manage the patient's condition:
- Antidepressants—if a depressed mood is observed.
- Tranquilizers—for pronounced anxiety and insomnia.
- Psychostimulants and nootropics—for decreased activity and energy levels (used with extreme caution).
Important: Tricyclic antidepressants and psychostimulants can provoke a psychotic exacerbation, so they are strictly prescribed in combination with potent antipsychotics.
The challenge of long-term treatment (compliance)
Eliminating acute symptoms does not mean complete recovery, so the physician's most crucial task is to convince the patient and their family of the necessity of long-term medication use.
Long-term therapy has its contradictions. Typical antipsychotics increase the risk of tardive dyskinesia, but discontinuing the drugs threatens a new psychotic episode. The solution is switching to modern atypical antipsychotics (clozapine, quetiapine, aripiprazole, etc.), which are less likely to cause neurological side effects during prolonged use.
To ensure successful cooperation (compliance), the physician should take into account the aspects that concern the patient: sleep quality, mood, appearance, and even sexual life.
Shock methods and rehabilitation
Shock therapies, such as electroconvulsive therapy (ECT) and insulin coma therapy, are rarely used nowadays because psychopharmacotherapy is more effective. ECT may be indicated for acute episodes with pronounced affect and in the early stages of the disease, as well as for severe febrile schizophrenia (along with plasmapheresis and hemadsorption).
Rehabilitation is a lengthy process. Even after delusions and hallucinations disappear, lethargy and sluggishness may persist. Patients frequently experience post-schizophrenic depression and severe distress due to the realization of their behavior during psychosis.
For successful rehabilitation, it is important to:
- Gradually return the patient to their usual activities.
- Not create a greenhouse environment at home and not shield them from everyday stresses.
- Encourage manageable household chores.
- In case of a persistent deficit, involve the patient in various activities in specialized institutions.
Briefly: answers to topical questions
What specific extrapyramidal disorders can typical antipsychotics cause?
Typical antipsychotics can cause the following extrapyramidal disorders:
- Acute dystonia—painful spasms of the face, neck, tongue, eyes, pharynx, and larynx.
- Drug-induced parkinsonism—tremor, generalized muscle hypertonia, amimia, shuffling gait.
- Akathisia and tasikinesia—restlessness, urge to move, agitation.
- Tardive dyskinesia—persistent facial dyskinesias, choreiform and athetoid movements in the extremities.
What are the contraindications for electroconvulsive therapy (ECT)?
There are no absolute contraindications for electroconvulsive therapy. Only relative contraindications exist, which include intracranial tumors with a risk of herniation. At the same time, it is specifically noted that a physiological pregnancy is not a contraindication. This treatment method is used for severe endogenous depressions and catatonic disorders, and its mortality rate is considered extremely low, associated primarily with anesthetic complications.
Class and exam questions
Can I stop taking pills if my delusions and hallucinations have gone away?
No, the disappearance of positive symptoms does not mean recovery. Stopping antipsychotics sharply increases the risk of a new episode.
What should I do if rigidity or tremors occur from antipsychotics?
These neurological side effects are managed by prescribing anticholinergic antiparkinsonian agents (e.g., cyclodol or akineton).
Do I need to completely shield a schizophrenia patient from household chores and stress?
No. Relatives should not create "special conditions." While taking medications, the patient should participate in household chores to the best of their ability; this is part of rehabilitation.
What else to study on this topic
- Differential diagnosis of schizophrenia with manic-depressive psychosis and hysteria
- First-rank symptoms according to K. Schneider
- Features of post-schizophrenic depression
- Management of patients with persistent deficits in specialized institutions
- Expert assessment of legal incapacity and disability in schizophrenia
Master the entire topic in the "Psychiatry" course
This is a summary. The course covers everything tested in classes and exams.
- Complete study guide on "Schizophrenia Treatment" and 499 more pages of the subject
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 7 video lessons on the subject
Other topics in "Chapter 22. Schizophrenia and Related Disorders"
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.