Categories: Psychotherapy
      Date: Jan 25, 2010
     Title: New Developments in the Maintenance Treatment of Schizophrenia Part I

With the advent of atypical antipsychotics such as clozapine (Clozaril), risperidone (Risperdal), and olanzapine (Zyprexa) in the late 1980s and 1990s, many patients with schizophrenia were for the first time able to get relief not only from their positive symptoms (hallucinations, delusions, disorganization) but also from their negative symptoms
(emotional blunting, apathy, lack of drive, lack of personal care). Consequently, the number of patients in psychiatric institutions dropped significantly over the past 20 years. However, many patients continued to suffer from the devastating effects of the disease. Many of these individuals are noncompliant with treatment, particularly
medication.

The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) revealed 74% of patients discontinued their medication within 18 months due to poor tolerability or lack of efficacy (Liebermanet al., 2005). Predictors of noncompliance from other studies suggest additional factors that include substance use, lack of insight, unsupportive families, and poor therapeutic alliances during their hospitalization (Olfson et al. 2008).
Over the years, there have been many innovations in care aimed at overcoming noncompliance, including assertive case management, outpatient civil commitments, and new formulations of medications. Assertive case management, where mental health workers go out into the community
to meet the patient, is felt to help, as are psychoeducation, family support, and development of drugs that may lead to increased compliance. The first generation (typical) antipsychotics appeared in the
1950s. This resulted in great improvement in positive symptoms and many patients were able to be released from psychiatric institutions. However, noncompliance remained an issue. In the 1960s through the early 1980s, several products appeared in the form of depot injections. The depot medications are injected intramuscularly, and the earliest ones contained both medication and an
oily substance that slowed the rate of absorption. This allows for a more constant and reliable dosage to enter the patients blood stream than with oral medicines. The depot forms of medication needed only to be injected every few weeks instead of daily. This was another gigantic step forward.
Unfortunately these medications, including haloperidol (Haldol) decanoate and fluphenazine
(Prolixin) decanoate, still subjected patients to risks of tardive dyskinesia at a rate similar to the other first generation medications and did not address negative symptoms. Tardive dyskinesia is a long-term
adverse effect that may be irreversible. It involves uncontrollable movements of limbs, mouth, face, and trunk; the etiology is uncertain.