Antipsychotics as the Treatment for Schizophrenia

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Mental health disorders appear in a variety of forms that affect’s individual’s characteristics and the way they interact with others. Schizophrenia is one of the most common forms of mental health disorder, that comes from the Greek words 'split' and 'mind'. Someone with schizophrenia is often known to have a split personality. In the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-V) schizophrenia is defined as a severe and chronic mental health disorder described by disturbances in thought, perception and behaviour (Hurley, 2019). Schizophrenia is a relapsing episode of psychosis and affects the way you think. Many people with this disorder often see, hear or believe things that aren’t real (NHS, 2019).

Schizophrenia can be often difficult to diagnose (Rethink Mental Illness, n.d). There are different types of schizophrenia depending on the kind of symptoms a patient shows. The International Classification of Diseases (ICD-10) manual describes five main types of schizophrenia. (Hebephrenic) which is also known as disorganised and individuals with this often show little or no emotions in their facial expressions, voice, or mannerisms. (Catatonic) is rarer than the other types. (Undifferentiated) show signs of paranoia. (Residual) is where negative symptoms are more noticeable early on and they get worse quickly. Finally, (Paranoid) which is the most common type of schizophrenia and individuals may develop this later in life than the other types of schizophrenia (Rethink Mental Illness, n.d).

In 2013 the (DSM-V) changed the process of classification to bring all these types underneath a single heading known as schizophrenia (Brazier, 2017). There is no known cause, but it’s believed to be a combination between genetics, brain chemistry and a range of environmental factors (World Health Organization, 2019).

Schizophrenia is a common illness that one in a 100 people will develop it (Mental Health UK, n.d). Symptoms are usually visible in early adulthood and are more present earlier among men, which tends to affect them more severely (Burton, 2015). Symptoms of schizophrenia are divided into three categories positive, negative and cognitive symptoms. Positive symptoms are experienced in addition to reality whereas negative symptoms affect individual’s ability to function (Mental Health UK, n.d). Positive symptoms include hallucinations, delusions and disorganised thinking. Some negative symptoms include social withdrawal, emotionless, and lack of motivation these can vary in length of time you experience them and the severity (Rethink Mental Illness, n.d). Cognitive symptoms are the newest classification in schizophrenia and may contribute to the larger pattern of symptoms such as difficulties with attention, concentration and memory (Burton, 2015). A person with these symptoms is often unable to deal with everyday life. The early stage of schizophrenia is called the prodromal phase, and this is where an individual’s sleep, emotions, motivation, communication and ability to think changes. An acute episode is if a person becomes unwell, during this phase, individuals may feel panic, anger or depression. When this acute episode first takes place, Individuals are usually not prepared for this and it can be shocking experience for them (Mental Health UK, n.d).

Schizophrenia is treatable, but requires long life treatment. There are many different types of treatments for schizophrenia that can be treated with a combination of therapy and medicine (NHS, 2019). For example, People with schizophrenia can be treated by community mental health teams (CMHTs) who provide support for individuals by using a range of different services including assessments to help them follow treatment programmes, advising therapies and lifestyle choices that encourage support for good mental health (The Queen’s Nursing Institute, 2020). Another type of therapy treatment includes care programme approach (CPA). This ensures individuals receive the right treatment for their needs, by having assessments, care plan, key worker and reviews. Also, Crisis resolution teams (CRT) is a where individuals can telephone in. If the symptoms are more serious acute schizophrenic episodes this may require admission to a psychiatric ward at a hospital or clinic (NHS, 2019). Types of psychological treatments include family therapy, arts therapy which is designed to promote creative expression and cognitive behavioural therapy (CBT) which is one of the most popular psychological treatment for schizophrenia. It can help individuals identify the thinking patterns that are causing them to have these unwanted feelings and behaviour and try learn how to change this by having more realistic and beneficial thoughts (NHS, 2019).

One form of effective treatment is a type of medicine known as Antipsychotics neuroleptic drugs. These are psychiatric drugs that are used to treat types of mental health disorders whose symptoms include psychotic experiences (Mind, 2016). These are usually recommended as early treatment for the symptoms of an acute schizophrenic episode, as they help to reduce the positive symptoms such as delusions and hallucinations, which allows the patient to function more effectively and appropriately (Johnson, 2020). Researchers believe that some psychotic experiences are caused by the brain producing too much of a chemical called dopamine which are neurotransmitters that passes messages around your brain. Antipsychotic drugs are known to block some of these dopamine receptors referred to as the D2 receptor and reduce the flow of these messages (Mind, 2016). Antipsychotics can be taken in forms of tablets, liquid, or as an injection.

There are two categories of antipsychotics first generation (older) antipsychotics and second generation (newer) antipsychotics. Both types work well but they differ in side effects, such as sleepiness, drowsiness, dry mouth and shakiness etc (Mind, 2016). Two of the chemical groups of drugs used to treat schizophrenia include Phenothiazines – e.g. chlorpromazine (Thoradine) and Butyrophenones – e.g. halperidol (Haldol). The Older First generation Antipsychotics was first developed in the 1950s and is often referred to as ‘typicals’. Some of the main types of these are Benperidol (Anquil), Chlorpromazine (Largactil) and Flupentixol (Depixol). However not all of them act in the same way and some of these may cause movement disorders and may make individuals drowsy (Mind, 2016). First generation antipsychotics work by blocking the effect of D2 dopamine receptors on the brain or restore the balance of dopamine with other chemicals in the brain that effectively control the hallucinations, delusions, and confusion of schizophrenia (Tartakovsky& Grohol, 2020). They also block D2 receptors in areas outside of the mesolimbic pathway, which can result in a worsening of the negative symptoms (Tung & Procyshyn, 2007).

The Newer Second generation Antipsychotics was first developed in the 1990s and is often referred to as ‘atypicals’. Some of the main types of these are Amisulpride (Solian), Aripiprazole (Abilify,) and Clozapine (Clozaril). However, the newer antipsychotics can cause serious metabolic side effects, including rapid weight gain (Mind, 2016). Antipsychotics work quickly in comparison to other psychiatric medications. The side effects can be serious that it can affect patient’s daily activities. Second generations antipsychotics work by blocking the D2 receptors as well as acting upon serotonin receptor, the 5HT2A receptor. When D2 and 5HT2A receptors are linked and they treat both the positive and the negative symptoms (Tung & Procyshyn, 2007). They can also affect negative symptoms such as reducing emotional expression the feeling of anxiety or aggression (Lawton, 2012). It might take longer to reduce other symptoms, such as hallucinations or delusional thoughts. Antipsychotics are only effective in 70%, the atypical antipsychotics appear to fall into two groups, those that have a low affinity for dopamine D2 receptors and those that are selective for dopamine D4 receptors (Seeman et al., 1997).

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Psychological treatments for schizophrenia work best when they are combined with antipsychotic medication and are only needed until the acute schizophrenic episode has passed (NHS, 2019). People with schizophrenia who take this medication will find that their hallucinations or delusions will decrease and sometimes may disappear, as it helps control these symptoms. Antipsychotic drugs have greatly improved, they are effective, cheap to produce, easy to manage and can have a positive effect on many individuals (Johnson, 2020). Both first and second generation antipsychotics are effective in reducing positive and disorganization symptoms but are only minimally effective for negative and cognitive symptoms which contribute significantly to the incapacity associated with schizophrenia (Bruijnzeel et al., 2014). However, (Kahn et al., 2008) found that antipsychotics are generally effective for at one year, but second- generation drugs were no more effective than first-generation ones. Despite this, the suggested clinical effectiveness of second- generation antipsychotic drugs compared with first-generation antipsychotic drugs is still debated (Kahn et al., 2008). Antipsychotics can help to reduce the symptoms of schizophrenia, but they don’t cure schizophrenia, instead they dampen symptoms down so that patients can live normal lives (Johnson, 2020). Some of the side effects of newer antipsychotic drugs are easier to manage (Rethink Mental Illness, n.d). Meta-Analysis by Crossley Et Al (2010) suggested that Atypical antipsychotics are no more effective but do have less side effects (Johnson, 2020).

Drugs that are the most effective at blocking dopamine receptors also are the most effective against schizophrenia (Li et al., 2016). Some of the Drugs that lessen schizophrenia block post-synaptic dopamine receptors (Dimitrelis & Shankar, 2016) However these drugs do not work on all patients. Over time the dosage of drugs can be reduced by minimum effective amount as the patient becomes more self-assured in their understanding of the illness, which can then help reduce the chances of side effects such as parkinsonism and tardive dyskinesia which manifests as involuntary facial movements such as blinking and lip smacking of being developed (IB, 2017). While antipsychotics may be effective, the severity of the side effects mean the expenses outweigh the benefits therefore they are not an appropriate treatment. (IB, 2016). People with schizophrenia are 2-3 times more likely to die early than the general population. This is often due to physical diseases, such as cardiovascular disease, metabolic disease and infections (World Health Organization, 2019). There is little evidence from comparisons of first-generation antipsychotics and second- generation antipsychotics that estimate differences in risk for adverse effects such as mortality (Eisenberg, 2013). One study showed that high antipsychotic use was associated with higher mortality due to natural causes. As a result of this higher mortality among these patients, may be related to side effects of high antipsychotic exposure mortality risk increased more in women than in men. The finding supports previous literature that reports women require lower doses of antipsychotics and may also have a greater risk for side effects than men at higher dosage.

Second generation antipsychotics Clozapine has also been shown to be more effective in terms of managing treatment-resistant schizophrenia than other antipsychotics as it focuses on multiple neurotransmitters, not just dopamine. This drug is 30% effective in controlling schizophrenic episodes in treatment-resistant patients, compared with a 4% efficacy rate with the combination of chlorpromazine and benztropine. Clozapine has also been shown to increase serum sodium concentrations in patients with polydipsia and hyponatremia (Patel et al., 2014). However, the side effects of these can be severe such as high-dose clozapine has been associated with serious adverse effects, such as seizure. Clozapine could also affect the loss of the white blood cells that help to fight infection as your immune system isn’t working as well as it should because of this. Other individuals can experience serious neurological symptoms so constant health checks are required. (IB, 2016). In contrast some of the newer antipsychotic drugs, such as risperidone and olanzapine are safer and better tolerated, but they might not treat the illness as well as clozapine (Johnson, 2020). Antipsychotics have been consistently found to be superior to placebo in reducing risk of relapse in schizophrenia (Gilbert et al., 1995;Leucht et al., 2012) (Bruijnzeel et al., 2014). Thornley et al carried out a meta-analysis comparing the effects of Chlorpromazine to placebo conditions. They found Chlorpromazine to be associated with better overall functioning which suggest that Drug therapy is an effective treatment for SZ (Johnson, 2020).

However (Patel et al., 2014) study suggest that both augmentation therapy with Electroconvulsive therapy (ECT) or a mood stabilizer and combination therapy with antipsychotics may be considered for patients who fail to show an adequate response to clozapine.

Although medication is the most effective treatment for schizophrenia, there is a high risk of symptoms returning after individuals stop taking medication (Mind, 2016). This might be due to medication not working or the side effects being intolerable. Individuals who stop taking their medication are at increased risk of relapse, which can lead to hospitalization (Progress In Mind, 2018). Long-term studies show that a small portion of people with remitted first episode psychosis show that from 3% to 22% avoid relapse if they do not receive maintenance treatment and only 3% of patients in Munich followed for fifteen years had escaped relapse (Progress In Mind, 2018).

Randomized controlled trials (RCTs) are consistent in showing that the long-term use of an antipsychotic reduces relapse risk. In the meta-analysis undertaken by Stefan Leucht showed that the one-year relapse rate with placebo was 64% while that with active treatment was 27%. The rates of re-hospitalization were 26% with placebo and 10% with antipsychotic maintenance (Progress In Mind, 2018). Although (RCTs) studies have shown that antipsychotics are highly effective in reducing symptoms and improving quality of life during short‐term interventions, it has been believed that the use of antipsychotics in long‐term treatment can lead to brain atrophy or a lower rate of recovery (Tiihonen, 2016). Individuals may have to stick to antipsychotics for a long time depending on their symptoms. Some individuals may take antipsychotics once, while others have to take a regular dose to prevent symptoms reappearing. Some individuals do not respond to drug treatment (Johnson, 2020).

By sticking to treatment individuals can lead successful lives. Regular use of antipsychotic medication is known to improve overall outcomes and diminish risk of relapse all patients are in danger of relapsing but without medication the relapses are common and more severe which suggest the drugs are effective, but medication can only help up to a certain extent. Individuals may have to use other treatments such as psychosocial and support therapies (Tartakovsky& Grohol, 2020). Sometimes when people with schizophrenia become depressed, it is common to prescribe them anti-depressants at the same time as the anti-psychotics (Johnson, 2020). As they are good at reducing symptoms and living well. To also reduce the risk of relapse individuals could use CBT together with antipsychotics as it would allow the individual to discuss their illness without it causing any more damage whilst also discovering methods of dealing with symptoms and how to detect a relapse before it occurs (IB, 2017).

In conclusion antipsychotics are a useful way at treating schizophrenia, which is a complex disorder that requires quick treatment at the first signs of a psychotic episode. It clear that antipsychotics do not deal with the cause of schizophrenia, but only works at hiding or fixing the symptoms. However, doctors should consider a potential for treatment the adverse effects when developing a treatment plan. Future research should address gaps in treatment and potentially find a cure for schizophrenia by finding ways of dealing with symptoms and how to identify a relapse. By developing more effective and safer drugs.

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