Medication
What Types of Antipsychotic Medications Are There?
Conventional Antipsychotics
Conventional antipsychotics have been available since the mid-1950's and are the least costly of the schizophrenia medications. They were the first antipsychotic medications developed that effectively relieved psychotic symptoms, and allowed many people diagnosed with a mental illness who had been living in institutions to live in the community. Conventional antipsychotics can be effective in decreasing the symptoms of schizophrenia (hallucinations, delusions, and unusual behaviors); however, there are some people for whom they provide little relief.
Adverse side effects associated with conventional antipsychotics include the following major movement disorders:
Akathisia- subjective feelings of distress and discomfort, agitation, restlessness, frequent arm and leg movements, non-localized pain.
Dystonia- sudden involuntary muscle contractions, bizarre and uncontrolled movements of face, neck, tongue and back, oculogyric crisis---often mistaken as seizure activity.
Parkinsonianism- slowed movement, expressionless face,
shuffling gait, tremors
Tardive dyskinesia- "late appearing movement disorder"
-- most devastating side effect of therapy. Jerking muscle movements,
body rocking, and tic-like movements of face and tongue--can progress to the
entire body or remain mild. It is seldom reversible. Increases with age and
duration of drug use.
Atypical Antipsychotics
Clozapine was introduced in 1990 and is an atypical antipsychotic that may be placed in a class by itself because it can help people who do not respond to conventional antipsychotics. For this reason, it is considered the drug of choice for treatment of refractory (resistant) schizophrenia. Clozapine is able to treat the positive as well as the negative symptoms of schizophrenia. Positive symptoms of schizophrenia are abnormal thoughts and perceptions and include disordered thinking, delusions, and/or hallucinations. Negative symptoms of schizophrenia are loss or decrease of normal functions that may include blunted affect, impaired attention, avolition (when a person lacks energy, spontaneity, and initiative), and anhedonia (lack of pleasure or interest in activities that the patients once enjoyed). As a result of these negative symptoms, persons diagnosed with schizophrenia may withdraw from society and every-day life. Research on clozapine at this time has not indicated side effects such as those listed above (akathisia, dystonia, parkinsonism, and tardive dyskinesia). Unfortunately, the rare possibility of agranulocytosis (a severe adverse side effect involving the loss of white blood cells that fight infection), requires that recipients taking clozapine be monitored with blood tests every one to two weeks. The prevalence of agranulocytosis has a 1% incidence rate and is potentially life threatening (University at North Carolina (2002), Health Center (2002)).
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Antipsychotic Medications for Schizophrenia |
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Conventionals (traditional)
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Atypicals (newer over last 10 years)
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Medication treatment improves recipient outcomes. More than 100 research studies have confirmed that antipsychotic medications can decrease the psychotic symptoms of schizophrenia.
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Antipsychotic medications should be considered as an option for treating schizophrenia. It is important to rely on evidence-based guidelines when selecting an antipsychotic medication (Mellman et al., 2001).
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For people on antipsychotic medications, regular neurological screening tests such as AIMS should be administered.
Other atypical antipsychotics include risperidone (1993), olanzapine (1996), quetiapine (1997), and ziprasidone (2001), and are designed to be effective against both the positive and negative symptoms of schizophrenia. They have been shown to improve cognitive performance and negative symptoms compared to conventional medications.
Connecting People to Evidence-Based Medication TreatmentThere is presently extensive evidence and agreement on effective medication treatments that help people diagnosed with a severe mental illness. Evidence-based practices are interventions for which there is consistent scientific evidence showing that they improve recipient outcomes. For example, research shows that treating schizophrenia with antipsychotic medications in certain dosage ranges over specified periods of time may prevent or delay relapses. In order for medication treatment for people diagnosed with a severe mental illness to qualify as evidence-based, it needs to include practices that research has shown are critical for effectively improving recipient outcomes: a systematic approach to medications, measurement of outcomes, documentation, (Mellman et al., 2001). These evidence-based practices should be utilized with individuals who choose medication treatment.
The physician and recipient should work in a partnership as equals, and when appropriate (with recipient's consent), a support network should work closely over time to find the combination of medication that works best. This level of shared decision-making and partnership may improve recovery outcomes. Unfortunately, not everyone responds to the first medication that is tried, and in these cases, it is important that the recipient and physician work closely together to continue to try other medications. No one should settle for an inadequate response until all the options have been tried.
Family, Recipient, Cultural PerspectivesThe development of the descriptions for these OMH Priority Evidence-Based Practices included extensive involvement from clinical experts, recipients of mental health, family members, and people who represent culturally diverse viewpoints. Their perspectives are critical to the understanding of these important practices and programs in mental health.
Family Perspective
Families generally view psychotropic medication as an essential ingredient to good treatment and recovery. When a person diagnosed with a mental illness is taking prescribed medication, it is important that family members understand what the medications do; how long they take to work; what adverse side effects may occur; how different classes of medicines differ from one another; what they cost; and when and whether it is a good idea to switch medication, including switching to new medications.
Families can play an important role in evaluating the quality of pharmacological treatment that their relative is receiving. Close family members are often the first to observe the signs of relapse that may be due to their relative being under or over-medicated. When this occurs, families need to talk to their relative to find out the reasons for symptoms relapse such as the relative's unacceptance of the illness, uncomfortable side effects, or impaired judgment- and to work closely with both the professionals and relative to overcome barriers to care.
Recipient Perspective
Recipients expect to have a psychiatrist who listens and works with their input in determining the right dose and medication. Ideally, education and information about medications and choices leading to a shared decision would be the goal. When recipients are uncomfortable with some aspect of their reaction to medication, the most common complaint is that the doctor ignores their suffering by saying you need to give it more time. Genuine, fully informed consent with regard to medications should include information about tardive dyskinesia, dystonia, and other medication induced movement disorders previously mentioned. Also, the impact of medication on overall health such as weight gain and diabetes should be explained. The effect of medications on sex drive and sexual performance should also be discussed.
Cultural Perspective
While medications are important in the treatment of mental illness, research has shown metabolism differences, diet, and use of dietary supplements can alter the effectiveness and increase side effects of medications. Due to a host of factors including stigma, historical mistrust and fear of government, many minorities do not seek mental health treatment. Therefore, first encounters are often at a point of greater distress and disabling condition. There is additional concern for minorities as research has shown a pattern of misdiagnosis and subsequent prescribing errors due to differences in cultural expression of distress, misunderstanding of culture bound syndromes and discrimination. For example, patterns were noted in overly used schizophrenia diagnosis for African Americans who in actuality were suffering from depression.
Measuring Your OrganizationQuality Measures for the Treatment of Schizophrenia
The above hyperlink directs you to schizophrenia measures and data sources, organized by domain of quality. These quality measures for schizophrenia may be found with further discussion in the research article: Hermann RC, Finnerty M, Provost S, Palmer RH, Chan J, Lagodmos G, Teller T, Myrhol BJ. (2002). Process measures for the assessment and improvement of quality of care for schizophrenia. Schizophrenia Bulletin, 28 (1), 95-104.
Description of Quality Measure for Medication Treatment
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Medication Treatment |
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Description |
Percent of adult recipients diagnosed with schizophrenia diagnosis who were prescribed an antipsychotic medication |
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Numerator |
Number of unduplicated adults in the denominator receiving antipsychotics |
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Denominator |
All persons age 18 and older with a schizophrenia diagnosis served by your facility |
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Data Source |
Pharmacy and administrative claims |
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Developer |
NYSOMH2 (adapted from Schizophrenia PORT10 Acute Phase Pharmacotherapy measure) |
Researchers indicate that adherence to specific programmatic standards (referred to as fidelity to implementation) is required to produce desired outcomes for recovery. Fidelity scales are intended for use by the mental health program leaders and public mental health authorities, allowing the program leaders to evaluate their own programs. For more information see Torrey, W.C., Drake, R.E., Dixon, L., Burns, B.J., Flynn, L., Rush, A.J., Clark, R.E., & Klatzker, D. (2001). Implementing evidence-based practices for persons with severe mental illnesses. Psychiatric Services, 52 (1), 45-50.
ReferencesHealth Center website. Clozapine and agranulocytosis (Part 1): What is the incidence of mortality & does stringent monitoring help reduce mortality? August 19, 2002. http://www1.health-center.com/pharmacy/antipsychotics/clozapine/clozapine_stud/agran1.htm).
Mellman, T.A., Miller, A.L., Weissman, E.M., Crismon, M.L., Essock, S.M., Marder, S.R. (2001). Evidence-based pharmacological treatment for people with severe mental illness: A focus on guidelines and algorithms. Psychiatric Services, 52 (5), 619-625.
Mueser, K.T., Gingerich, S. Coping with schizophrenia: a guide for families. Oakland: New Harbinger Publications, 1994.
University of Northern Carolina at Chapel Hill. Handout: Antipsychotic medications. August 19, 2002. http://www.unc.edu/depts/biopsych/Psychotic.handout.html
Weiden, P.J., Scheifler, P.L., Diamond, R.J., Ross, R. Breakthroughs in antipsychotic medications: a guide for consumers, families, and clinicians. New York: W.W Norton and Company, 1999.