When a person is diagnosed having a psychotic disorder, especially schizophrenia, the first choice of therapy is to give antipsychotic drugs. Of course, for decades the antipsychotics have helped the schizophrenics to come out of distress and disability (Frank, E. & Judge, R. (2001). It is one of the reliable methods of controlling the chronic and distressing symptoms of schizophrenia. But it has various challenges associated with it. The side effects, aversion of the patients to take medications, drug resistance, etc. are issues that challenge the therapy by antipsychotics. A metanalysis is carried out to find out the current status of antipsychotics and its effectiveness. The issues beyond antipsychotics are also explored in this study. A scan of viewpoints of the different schools of thought relating to psychotics, schizophrenia, antipsychotics and other parallel therapies, is what is intended by this metanalysis.
Schizophrenia
Schizophrenia is a psychotic disorder. It is a serious brain disorder that deforms the way a person behaves. A person with schizophrenia thinks, acts, express emotions, perceives reality, and relates to others in a weird manner. It is the most disabling mental illness that not only affects the patient but also people around the patient. When the symptoms occur, it puts a severe stress and strain on families. The person with schizophrenia mostly has problems adjusting in community, at work, at school and in close relationships. Cure for this illness is not complete, but it can be controlled with a set of treatments.
Biological basis of schizophrenia is unknown, but the biological basis of symptoms is found to be linked to overactivity of the dopamine neurons Stahl, S. M.(1998). For last thirty years it has been observed that diseases or drugs that increase dopamine will enhance or produce positive psychotic symptoms, while drugs that decrease dopamine release will reduce or stop psychotic symptoms. The treatment of psychosis that focused on controlling , rather blocking dopamine receptors based on above mentioned observation is termed as Dopamine hypothesis and this hypothesis was the major tool of tackling the psychotic symptoms.
Schizophrenia is a chronic disease that is treatable. What causes schizophrenia is unknown, it runs in families and seem to have a link to biochemical abnormalities in the brain. Both, men and women have an equal chance of becoming psychotics, irrespective of nationality and ethnic origins (Paykel ES, Cooper Z. (1992)). But, onset of this disease in men is early, men experience the first symptoms in their late teens or early to mid-20s; while, for women, the symptoms are noticed a bit later, in their early to mid-20s to mid-30s.
Antipsychotics
The treatments known for psychotic illness includes a combination of antipsychotic medication, psychological therapy / counselling and community support. Taking antipsychotic medication is the most important initiative in getting rid of the symptoms, but other collateral therapies such as constant clinical support in the community, psychological therapies, education about the illness and how to tackle it, psychosocial rehabilitation, and employment support are also found to be effective. In this document, we are going to focus on the metanalysis of the antipsychotic medication (antipsychotics) and issues related to it.
Antipsychotic medications are classified into two types: atypical and typical. Typical drugs were of the older generation, and atypical are newer generation drugs. Both are found to be effective in treating schizophrenics, but atypical medications are found to have some advantages over the typical ones Stahl, S.M. (1998). The distinctions between the two are
- Atypical medications have fewer side-effects such as wobbling or stiffening of muscles
- Atypical drugs have less risk of developing ‘tardive dyskinesia’
- There is some evidence that the atypical medications are effective in improving overall mood, thinking and energy, but for some people typical medications suit better.
Effectiveness of Antipsychotic Drugs
As in other applied fields psychiatry also has temporally based schools, first generation and second generation drug administration schools. Jaffe, A.B. & Levine, J.(2003) studied the efficacy and effectiveness of antipsychotics in a peculiar way. For their research, to test their hypothesis, they relied on the organizational data. They gathered the data from The Nathan Kline Institute’s patient database to study the outcome of switching the drugs of one generation to another. They hypothesised that the second generation antipsychotics have a lesser chance of premature discontinuation when switched from first-generation. They also clearly brings out the distinction between the terms efficacy and effectiveness. According to them, efficacy is associated with a treatment that is done under ideal conditions and effectiveness is concerned whether a treatment works in conditions of routine care.
Their study indicates that, as a class, second-generation antipsychotics was less likely than first-generation agents to be associated with premature discontinuation of an antipsychotic regimen, both when used as the initial medication regimen following hospitalization and as the second regimen following a prior medication switch. Jaffe, A.B. & Levine, J.(2003) study implies that the patients who are used to a particular generation of drug find it difficult to adapt to the new regimen, which indicates that the effectiveness of antipsychotics depends on adaptiveness of the psychotics. Switching drugs may not have positive outcomes , however, advanced may be a drug.
In favour of Second Generation Antipsychotics
A study by Conley, R.R. &, Kelly D.L. (2002) highlights the advantages of atypical antipsychotics and reveals that this class of drugs is more beneficial. They disapprove the dopamine hypothesis by stating that it is incomplete and is not ideally suited to treat all kinds of schizophrenia. The traditional antipsychotics such as chlorpromazine have the ability to block dopamine D2 receptors in the brain, and the clinical experiments in those days led to the hypothesis that an excessive presence of dopamine causes the symptoms. The function of serotonin was not considered as aggressively as of the dopamine. The new generation drugs such as clozapine, risperidone , quetiapine, etc. have relatively high serotonin to dopamine binding ratios. Serotonin based drugs are found to be better in treatment of negative symptoms. Other benefits of second generation psychotics are lower rates of relapse, cost effectiveness , lower cognitive impairments, etc. Though this class of drug is better, Conley, R.R. &, Kelly D.L agrees that still more understanding of the exact mechanism of action is to be gained, and this understanding can pave the way for new drug targets.
Adverse Effects of Antipsychotics
In using or administering antipsychotics, a trade off is needed, that is what the research by Muench, J. & Hamer A. M. (2010) shows. Though antipsychotics is symptoms alleviating , they are not only life shortening, but also has an adverse effect on physical conditions. A score of side effects is reported to be associated with regular use of antipsychotics. In their study, they found more variability among specific antipsychotic drugs than in between first and second generation antipsychotics. It is observed that the new generation antipsychotics are having its toll on the metabolism relating to obesity and type 2 diabetes. While first generation drugs are affecting the muscular movements such as parkinsonism. Other than these differences, both drugs equally affect health with temporary and long term effects. The antipsychotics are likely to increase sedation, cause sexual dysfunction, promote postural hypotension, trigger cardiac arrhythmia, and even can lead to cardiac death. They caution the primary care physicians to take note of the adverse effects of psychiatric medicines, advises to adjust or change medications as needed to reduce interaction effects and work with psychiatric colleagues for effective treatment of the patient.
Is there alternate to Antipsychotic medication?
Though antipsychotic medication is very much helpful in weakening positive symptoms of schizophrenia and reducing relapse, some patients fail to respond to the medication, even to new generation drugs. In such cases, the need for non pharmacological treatment arises, probably a psycho-social intervention. Already an established system of intervention exists; Cognitive behavior therapy (CBT). Sensky T, Turkington D, Kingdon D, et al.(2000) have demonstrated that CBT really can work in the treatment of Schizophrenics.
This CBT was specifically developed for schizophrenics. Two groups of patients were there in this study, one received full package of the CBT for schizophrenics and another one received befriending intervention (control group). For befriending group, the therapist remained empathic and non-directive and discussed with the patient neutral topics such as hobbies, sports, weather, current affairs, etc. Sensky T, Turkington D, Kingdon D, et al.(2000).
CBT intervention was an elaborate process, with distinct stages. For each of the positive symptoms, specific CBT techniques were used. For example, to tackle the auditory hallucinations , the therapist and the patient, developed a critical analysis of the beliefs about origin and nature of voice. The patient was asked to keep a voice diary / journal , which was later used for reattribution. Even coping strategies were jointly developed (Sensky T, Turkington D, Kingdon D, et al.(2000)). Even negative symptoms were tackled with specific interventions ( , but only after positive signs were addressed. Patients were encouraged to write a diary about the mastery in overcoming the symptoms and the pleasure they gain in leading a normal life.
The intervention was extended up to nine months, and another nine months follow up was carried out. The researchers found that CBT group showed signs of progress during the follow up period and concluded that CBT is effective in treating negative as well as positive symptoms, particularly for the patients who show resistant to antipsychotic medication. Sensky T, Turkington D, Kingdon D, et al.(2000).
What if Patient refuse to take Antipsychotics?
Very interesting phenomenon that challenges the hard work of the psychopharmacologists is that many of the schizophrenics have a tendency to skip or resist taking antipsychotic schedules. When patient refuses to take medicine , it is not just a medical problem , it has various other implications too. If the medication is administered with coercion or by force, it can sometimes be interpreted as encroachment into the rights of the patient. A non- cooperating patient is beyond medical predicament. Let us explore the study by a score of researchers Morrison, A. P., et al. (2014) who strongly propose CBT from a different perspective.
There are many schizophrenic patients who discontinue or refuse to take antipsychotics. What can we do to such patients?. Morrisson, A. P., et al.’ s study (2014) come as a solace and illustrates that non-drug intervention is equally good in tackling the psychotic symptoms. Their study was done on patients with 16 – 60 years of age, who had chosen not to take antipsychotic drugs. There were two groups of patients one who received cognitive therapy plus treatment as usual and the other group received only treatment as usual. The therapy and the follow up was for about 18 months and eight adverse and serious events happened during the study, which give collateral indications in support of the study. Two events occurred in the group that received cognitive therapy (one patient attempted overdose and one patient was presenting risk to others, both after therapy). In the treatment as usual group, six events occurred (two deaths, both were unrelated to trial participation or mental health; three compulsory admissions to hospital for treatment under the mental health act; and one attempted overdose). The researchers, interpret this study as, the cognitive therapy significantly, reduced psychiatric symptoms and seems to be a safe and acceptable alternative therapy for people with ‘schizophrenic’ disorders who have chosen not to take antipsychotic drugs. The researchers also point out that, though the present study support cognitive therapy, larger definitive trials are required.
Conclusion
In the process of this metanalysis, several other studies related to genetics, family therapy, yoga, etc. connected to psychosis and antipsychotics, were identified. But I have chosen only those studies which I believed as relating to the core of our purpose. The metanalysis has lead me to study the schizophrenia and its management from a larger perspective. A key question that emerges from this study is that, Is schizophrenia a result of chemical imbalances in the brain or is it a problem of perception , awareness or consciousness? Or is it a disintegration of the concept of self? Or is it a combination all? The research studies indicate that the patients are responding to both antipsychotic and non-antipsychotic treatments ( Frank, E. & Judge, R. (2001)). I intend to explore more on the nature of schizophrenia and find a satisfactory explanation to its occurrence and then attempt to resolve the question “ Can a psychotic patient choose the therapy he/ she wants?.” The answer to this question cannot be only from a medical angle, it has legal, psychological, social or even spiritual (awareness / consciousness) bearing.
, REFERENCES
Paykel ES, Cooper Z. (1992) Life events and social support. In: Paykel ES, ed. Handbook of Affective Disorders. 2nd ed. Edinburgh, Scotland: Churchill Livingstone; 149–170.
Frank, E. & Judge, R. (2001) Treatment recommendations versus treatment realities:recognizing the rift and understanding the consequences. Journal of Clinical Psychiatry, 62(suppl 22):10–15
Muench, J. & Hamer, A. M. (2010) Adverse Effects of Antipsychotic Medications American Family Physician. 2010 Mar 1;81(5):617-622.
Sensky T, Turkington D, Kingdon D, et al. A Randomized Controlled Trial of Cognitive-Behavioral Therapy for Persistent Symptoms in Schizophrenia Resistant to Medication. Archives of General Psychiatry.2000;57(2):165-172.
Gesteira, A., Barros, F., Martín, A., Pérez, V., Cortés, A., Baiget, M., Carracedo, A., (2010), Pharmacogenetic studies on the antipsychotic treatment. Current status and perspectives, Actas Esp Psiquiatr. Sep-Oct;38(5):301-16. (English review)
Jaffe, A.B. & Levine, J. (2003), Efficacy and effectiveness of first- and second-generation antipsychotics in schizophrenia. Journal of Clinical Psychiatry.; 64 Suppl 17:3-6.
Stahl, S.M. (1998).Essential Psychopharmacology: Neuroscientific Basis and Practical Applications, First Edition, Cambridge University Press, Camebridge , UK.
Morrison, A. P., Turkington, D., Pyle, M., Spencer, H., Brabban, A., Dunn, G., Christodoulides, T., Dudley, R., Chapman, N., Callcott, P., Grace, T., Lumley, v., Drage, L., Tully, S., Irving, K., Cummings, A., Byrne, R., Davies, L. M. & Hutton. P. (2014) Cognitive therapy for people with schizophrenia spectrum disorders not taking antipsychotic drugs: a single-blind randomised controlled trial. http://download.thelancet.com/flatcontentassets/pdfs/S0140673613622461.pdf , retrieved 22.02.2014
. Conley, R.R. & Kelly, D.L. (2002). Current status of antipsychotic treatment, Current Drug Targets. CNS Neurological Disordorders. Apr;1(2):123-8.
