PSYCHOSIS: 10. Treatment of Psychosis

Three primary forms of treatment for psychosis:

PSYCHOSOCIAL:

Social Skills Training

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Cognitive Therapy
Day programs
Stress reduction/relaxation training
Vocational rehabilitation

PHARMOCOLOGICAL:

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Antipsychotic medication. These medications are constantly being improved. Current antipsychotic medications result in fewer side effects than those administered years ago. Medications aimed at restoring some of the cognitive deficits, such as attention and memory problems, are being developed.

Cognitive capability is often a better predictor of how well a person with psychosis will function than are residual symptoms of psychosis.

Medications are usually started in the acute phase and are thereafter taken continuously, even if symptoms have remitted. Frequently, individuals with schizophrenia must continue taking these medications for several years because when not taking medication, the risk of relapse is 60-80% per year. On medication, the risk goes down to less than 20%.

EDUCATION:

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Understanding the illness. It is crucial for treatment centres to offer education to individuals with psychosis and their families about the condition, in order to ensure their understanding and to promote their active participation in treatment. This has been shown to improve outcome.

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Understanding the treatments: Education programs are generally conducted in the recovery phase and include information about the disorder itself, as well as information about medications, psychosocial treatments, the effects of street drug use, and early signs of relapse.

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Understanding the need for on-going care. These programs are also important in helping individuals with psychosis understand why it is important to continue taking medications, even after symptoms improve.
Family education. It is important to educate family members about the disorder and what to expect so that they will be prepared to help their loved ones with psychosis. Families need help to cope themselves.

GOALS OF TREATMENT

Decreasing positive and negative symptoms

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Maintaining or increasing cognitive abilities
Minimizing side-effects
Reducing secondary morbidity
Preventing relapse
Enhancing quality of life

MEDICATIONS

Antipsychotics or neuroleptics were discovered in the late 1950's by the Company Rhone Poulenc in Paris. This first antipsychotic drug was called Chlorpromazine which was used as a 'tranquilizer'. Its more specific benefits were recognized by accident. It was found to decrease positive symptoms such as hallucinations, delusions, and thought disorder.

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Antipsychotics are helpful in the acute stage of illness as they reduce symptoms. They also work to prevent symptoms from recurring and to prevent relapse. Studies show that those who take their medications as prescribed over one year have less than a 20% chance of having a relapse and returning to hospital. Those who do not take their medications have a 60- 80% chance of having a relapse and returning to hospital.

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There are two kinds of antipsychotic medications: classical and atypical. The classical medications are the original antipsychotic drugs that have been developed since the discovery of chlorpromazine. They work by blocking the dopamine receptors in the brain whereas the atypical drugs have other mechanisms of action. Both types are equally effective for approximately 80% of people with schizophrenia. Both types are very safe and neither type is addictive. The side effects are different.
ATYPICAL ANTIPSYCHOTICS
These medications produce less side effects and may be slightly more helpful for the negative symptoms than the classical antipsychotic medications.
1. Risperidone:

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This is an effective medication that is often used first.
2. Olanzapine:
This is an effective medication .
3. Quetiapine:
This effective medication needs to be taken twice a day.
4. Clozapine:

This may be the most effective of all the atypical antipsychotics. Unfortunately, not everyone can take this medication. Five % get a temporary decrease in their white blood cell count, which could lead to serious infections.

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They must discontinue the drug immediately. In order to prevent any problems, users must have weekly blood testing (every two weeks after 6 months) and discontinue the drug immediately should there be a drop in the white cell count. Other side effects include weight gain, sedation, constipation and increased saliva. This medicine has been proven to be more effective for some of the 20% or so of people who do not respond to other medicine.

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Finding the right medication can sometimes be like finding the right new shoes: trial and error can sometimes be necessary since shoe size doesn't always dictate comfortable fit.
Side Effects: One goal of treatment should be freedom from side effects. Many patients are able to achieve this with their doctors help. Side effects that may occur for some people include:

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1. Parkinsonian side effects:

Tremor
Slowed down movements
Muscle stiffness and rigidity

These side effects are helped by decreasing the dose of the medication, changing to a different medication, or by using side effect medications (benztropine or procyclidine are 2 kinds).
2. Anticholinergic side effects:

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Dry mouth (use sugarless gum, ice chips, lots of water)
Blurry vision (usually improves over time)
Constipation (add fibre like fruits and vegetables and drink lots of water 6-8 glasses a day)
Sedation (take the medication at night), improve sleep schedule, increase physical and mental activity during the day

3. Akathisia:

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Restlessness

Decreasing the dose of medication, changing the medication or adding side effect medication such as propranolol often helps this.
4. Acute Dystonic reaction:

Sudden muscle cramps

This rare side effect is helped by side effect medication administered immediately. This side effect tends to only occur when new medicine is started or increased rapidly and can be avoided by minimizing the dose.
5. Tardive Dyskinesia:

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Tic like involuntary movement of muscles.

The natural history of this is not fully known. It usually results from long-term use of classical (older) antipsychotic medication. It is prevented by using a low dose of medication and by staying on medication to prevent relapse. If tardive dyskinesia occurs, one should consider a change to an atypical neuroleptic.
ANTIDEPRESSANT MEDICATION

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Antidepressants were discovered in the late 1950's. They are used specifically for depression and are found to help 75-80% of people with Major Depression (not day to day ups and downs or grief). Those with major depression experience profound feelings of low mood and may also have low energy, change in appetite, change in sleep, poor concentration, feelings of guilt, thoughts of death, and ideas of self-harm. This lasts everyday, all day, for weeks, months or even years without treatment.
Antidepressant medication starts to work only after 1 to 4 weeks so some patience is required when getting started. Like antipsychotic medication, antidepressants are not addictive; however, care should be taken when stopping the medication. A physician can help you to slowly reduce and then stop the antidepressants when you agree it is time to do so to minimize side effects.
Some people experience one or more of:

Blurred vision in some people

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Constipation in some people
Sedation in some people
Insomnia in some people
Nightmares in some people
Weight gain in some people

There are no non-reversible side effects.
Many Antidepressants are long lasting and therefore some may be taken only need to be taken once a day.
MOOD STABILIZERS
Lithium: Lithium is an element that occurs naturally. It is a salt. It is present in Great Salt Lake and the Dead Sea. It's use as a mood stabilizer was discovered in the 1950 Os. Lithium works by balancing serotonin. It seems to help bi-polar (manic-depression) disorder in 75% of people. It is also sometimes used to boost the effect of antidepressants or antipsychotics in non-bipolar patients. Lithium can be detected in the blood by testing. Generally, when one begins to take lithium, blood tests are used to determine the correct dose. Lithium is usually taken once or twice daily.
Side Effects: Lithium is usually well tolerated but, in some, can cause:

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Dry mouth
Diarrhea
Tremor
Voiding too often
Thyroid problems: a minority of people in the long term can require thyroid hormone replacement to be taken daily.

SEDATIVES/ANTI-ANXIETY MEDICATIONS
Benzodiazepines: (e.g. ativan, valium) These have been in use since the 1960's and are very effective for anxiety or insomnia. They were originally marketed as non-addictive but after some years on the market it was concluded that they do cause dependency in a minority of people. Their effectiveness also tends to wear off after a time. Benzodiazepines are generally useful in the short term and require consideration in the long term.
What to do about Side Effects in General
People should learn:

How to identify side effects
Know what to do for the side effects
Discuss side effects with their doctor
Expect their doctor to take action to help reduce their discomfort

BARRIERS TO TAKING MEDICATION

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1. Forgetting
Forgetting medication doses is a problem for 40% of people with any illness. It helps to have cues to remember, i.e. take the medication with meals or after brushing your teeth. Have a pillbox or a docette, or request a blister pack from the pharmacy that is clearly labeled with dates and times. A simpler medication regime may be helpful, for instance, taking medication only once a day rather than 3 times a day.

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2. Refusing:
Sometimes it seems as if illness takes away one's autonomy or sense of freedom to make one's own decisions. Sometimes refusing medicine is the only way to assert any autonomy. Forcing the issue may only increase the difficulty. Setting clear expectations with consequences may be more helpful. Often the most helpful thing is education to convince people of the need for treatment and this would include information about the illness as well as information about medication. Ultimately, people should become as expert as possible on the nature and treatment of their illness in order to make the best choices. Trying to reduce and eliminate side effects is also crucial to help people to choose to continue medication.
WONDER DRUGS
A modern expectation is that medication or surgery will cure all our ills. Medication is an important first step, but inadequate without other treatment (for instance psychosocial rehabilitation including family counseling and education). There continues to be hope for better medicine.

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ALTERNATIVE THERAPIES
Mega vitamin treatment has been studied extensively and there is no good evidence that it works. There are no well-designed studies for other 'alternative' treatments.
We can accept that people may chose to use alternative treatments as long as they are not viewed as replacement for the well-proven treatments. It must be kept in mind that alternative treatments have not been studied for either effectiveness or safety, and anecdotal experience can be misleading. As well, the ingredients in non-pharmacological medicine are not monitored or standardized.
NON-MEDICINE TREAMENT
Non-medicine treatment works when added to medication; not as a replacement for medication. Medication alone is inadequate. The main barriers to non-medicine treatments like psychosocial rehabilitation are lack of insight and lack of motivation. Non-medicine treatments focus on control of stress and increase in social and occupational functioning (the two go together). Some examples are:

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A: Communication training

This can decrease the chance of relapse by 50%
We can all benefit from this
Families can learn to use clear, direct, 'low-key' communication strategies, which may help to reduce stress for everyone in the home

B: Skills training

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Can decrease relapse risk by 50%
Skills may be lost because of the illness just like with a stroke except the lost skills are not physical, but social. For instance, people may have difficulty with social skills, planning, leisure skills, cooking etc. These skills can be relearned (or learned) by using specific techniques and practicing. Competitive employment may be difficult but not impossible to attain if one follows a tailored step-wise plan.

C: Daily structure with meaningful activity of tolerable intensity

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Encourage the person to connect with their interests. Usually people require a period of convalescence before they are ready to resume much activity. They may start modestly with one thing a day. Encourage them to set goals, long term and short term plans that will lead to accomplishing long term goals. A good beginning might be to get up at the same time everyday and have a regular bedtime. Help create a structure for the day such as regular meal times, perhaps helping with meal preparation, doing simple chores, going for a walk, reading for 5 minutes, watching a limited amount of TV, a short time on a previously enjoyed pursuit such as music or computer, drawing or sewing. Once the person is able to accomplish this schedule, begin to slowly add in new activities.
D: Stress Management

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Goal setting as mentioned above is a very important stress management technique. Because psychosis is a stress vulnerable illness, learning to manage stress is important. Increased stress can provoke symptoms and make life more difficult in general.
Some excellent stress management techniques include 'Progressive Muscle Relaxation', 'Thought Stopping', and 'Creative Visualization'. There are tapes one can listen to that offer these techniques. They are available at bookstores. Physical exercise is great at reducing stress especially if it occurs regularly. A daily half hour walk does wonders to relax people. A safe secure living environment, a predictable schedule, and supportive people are a good basis for reducing stress. (See section on stress)
POTENTIAL CONSEQUENCES OF DELAYED TREATMENT
Longer duration of untreated psychosis has been shown to predict poor outcome. In addition, the illness process of relapse is most active and severe in the early years. The majority of deterioration in function occurs within the first five years and much occurs before the first acute psychotic episode. Potential consequences of delaying assessment and treatment include: