Covers antipsychotic drugs for treating schizoaffective disorder and side-effects of antipsychotic medications.

Basic Principles

Both drug and psychosocial therapies are necessary to successfully treat schizoaffective disorder. Because of the unemployment, poverty, and homelessness that often complicates schizoaffective disorder, drug therapy alone usually is insufficient. Drug therapy usually can stop the patient's psychosis, but often only social and occupational rehabilitation therapies can overcome the associated unemployment, poverty and homelessness. Recovering from schizoaffective disorder is an extremely lonely experience, and these patients require all the support that their families, friends, and communities can provide.

Schizoaffective disorder appears to be a combination of a thought disorder, mood disorder, and anxiety disorder. Thus the medical management of schizoaffective disorder often requires a combination of antipsychotic, antidepressant, and antianxiety medication. Unfortunately, after the first year of treatment, only a minority of schizoaffective outpatients remain on their oral medications. Thus long-acting, depot antipsychotic medications that last 2-4 weeks between injections (e.g., depot haloperidol, pipotiazine, or fluphenazine) usually are required to overcome this noncompliance problem.

Hospitalization

Treatment of an acutely psychotic patient often requires psychiatric hospitalization. The presence of adequate family or social supports will often shorten the length of this hospitalization, or permit the psychotic patient to be treated solely on an outpatient basis.

Antipsychotic Drugs for Treating Schizoaffective Disorder

Antipsychotic medications are the treatment of choice. Evidence to date suggests that all of the antipsychotic drugs (except clozapine) are similarly effective in treating psychoses, with the differences being in milligram potency and side effects. Clozapine (Clozaril) has been proven to be more effective than all other antipsychotic drugs, but its serious side-effects limit its use.

Individual patients may respond to one drug better than another, and a history of a favorable response to treatment with a given drug in either the patient or a family member should lead to use of that particular drug as the drug of first choice. If the initial choice is not effective in 2-4 weeks, it is reasonable to try another antipsychotic drug with a different chemical structure.

Often an agitated, psychotic patient can be calmed in 1-2 days on antipsychotic drugs. Usually the psychosis gradually resolves only after 2-6 weeks of a high-dose antipsychotic drug regimen. A common error is to dramatically reduce antipsychotic drug dosage just as the patient improves or leaves hospital. This error almost guarantees a relapse. Major reduction in antipsychotic drug dosage should be avoided for at least 3-6 months after hospital discharge. Decreases in antipsychotic drug dosage should be done gradually. It takes at least 2 weeks for the body to reach a new equilibrium in antipsychotic drug level after a dose reduction.

Side-Effects of Antipsychotic Drugs

Sometimes patients view the side-effects of the antipsychotic drugs as being worse than their original psychosis. Thus clinicians must be skillful in preventing these side-effects. Sometimes these side-effects can be removed by simply reducing the patient's antipsychotic drug dosage. Unfortunately, such reduction in drug dosage often causes patients to relapse back into psychosis. Therefore clinicians have no choice but to use the following treatments for these antipsychotic side-effects:

1. Acute Dystonic Reactions: These reactions are of abrupt onset, sometimes bizarre, frightening muscular spasms mainly affecting the musculature of the head and neck. Sometimes the eyes go into spasm and roll back into the head. Such reactions usually take place within the first 24 to 48 hours after therapy has begun or, in a small number of cases, when dosage is increased. Males are more vulnerable to the reactions than females, and the young more so than the elderly. High doses are more likely to produce such effects. Although these reactions respond dramatically to the intramuscular injection of antihistamines or anti-parkinson agents, they are frightening and are best avoided by starting with lower antipsychotic drug dosages. Anti-parkinsonian drugs (e.g., benztropine, procyclidine) should be prescribed whenever antipsychotic drugs are started. Usually these anti-parkinsonian drugs can be safely stopped in 1-3 months.

2. Akathisia: Akathisia is experienced as an inability to sit or stand still, with a subjective feeling of anxiety. Beta-adrenergic antagonists (e.g., atenolol, propranolol) are the most effective treatment for akathisia. These beta-blockers usually can be safely stopped in 1-3 months. Akathisia may also respond benzodiazepines (e.g., clonazepam, lorazepam), or to anti-parkinson drugs (e.g., benztropine, procyclidine).

3. Parkinsonism: Akinesia, a key feature of parkinsonism, may be overlooked, but if the patient is asked to walk briskly for some 20 paces, diminution of the swing of the arms can be noted, as can loss of facial expression. These parkinsonian side-effects of antipsychotic drugs usually respond to the addition of an anti-parkinson drug (e.g., benztropine, procyclidine).