5.+Pharmacotherapy

There are a variety of medications and treatment options available for psychosis and other psychotic disorders. Many clinicians recommend beginning treatment with atypical antipsychotic medication versus typical or conventional antipsychotic medication due to their increased benefits.
 * Pharmacotherapy **
 * Medications for Psychosis and Psychotic Behaviours **

/month ||= I ||= II ||= I || Risperdal M-tab || risperidone || 3-6 ||= I ||= II ||= I || Seroquel XR || quetiapine || 300-600 ||= III ||= III ||= I || fluoxetine || 3/25-12/50 ||= II ||= II ||= I || 405mg/ 4wk ||= II ||= II ||= I || I- Minimal, II-Moderate, III- Significant EPS- Extra-pyramidal symptoms: various movement disorders such as akinesia (inability to initiate movement) or akathisia (inability to remain motionless).
 * TABLE 8.1 Atypical Antipsychotic Medications ** (Peters-Strickland & Sincola, p. 62)
 * **Trade Name** || **Generic Name** || **Typical Dose**
 * (mg/day)** ||= **Sedation** ||= **Autonomic Effects** ||= **EPS** ||
 * Abilify, Abilify Discmelt || aripiprazole || 10-30 ||= I ||= I ||= I ||
 * Clozaril, Fazaclo || clozapine || 400-600 ||= III ||= III ||= none ||
 * Fanapt || iloperidone || 12-24 ||= I ||= II ||= I ||
 * Geodon || ziprasidone || 80-160 ||= I ||= II ||= I ||
 * Invega || paliperidone || 3-12 ||= I ||= II ||= I ||
 * Invega Sustenna || paliperidone || 78mg-156mg
 * Risperdal Consta || risperidone || 25-50mg/ 2 weeks ||= I ||= I ||= I ||
 * Risperdal,
 * Saphris || asenapine || 5-20 ||= I ||= I ||= I ||
 * Seroquel,
 * Symbax || olanzepine/
 * Zyprexa || olanzepine || 150mg/ 2wk-
 * Zyprexa, Zyprexa Zydis || olanzepine || 10-20 ||= II ||= II ||= I ||

Many clinicians strongly believe risperidone (Risperdal) is the number one choice of treatment particularly for those who are experiencing both positive and/or negative symptoms of first episode psychosis. Paliperidone (Invega) is also known to be just as effective as risperidone but is reported to have some extra-pyramidal symptoms (EPS). Secondary treatment options include aripiprazole (Abilify), olanzepine (Zyprexa), ziprasidone (Geodon) and quetiapine (Seroquel) as they are also known to be quite effective treatment options. It is also important to note that ziprasidone (Geodon IM), olanzepine (Zyprexa IM), aripiprazole (Abilify IM) are all available in injectable forms for emergency departments and hospitals in the case of an emergency. These injections are usually tolerated well by patients but can cause swelling in the injection site.

Again, risperidone (Risperdal) is considered the best treatment option for those suffering from multi-episode psychosis. Risperdal Consta, which is noted to be the only long-lasting atypical antipsychotic is considered to be an effective secondary treatment option. Other treatment options include haloperidol (Haldol), fluphenazine (Prolixin), trifluoperazine (Stelazine) and thiothixene (Navane).
 * Multi-Episode Psychosis **

(Peters-Strickland & Sincola, p. 63) (mg/day) ||= Sedation ||= Autonomic Effects ||= EPS ||
 * TABLE 8.2 Typical or Conventional Antipsychotic Medications **
 * Trade Name || Generic Name || Typical Dose
 * Haldol || haloperidol || 2-20 ||= I ||= I ||= III ||
 * Haldol Decanoate || haloperidol decanoate || 100-300mg/month ||= I ||= I ||= II ||
 * Loxitane || loxapine || 20-100 ||= II ||= I ||= II ||
 * Mellaril || thioridazine || 200-600 ||= III ||= III ||= II ||
 * Moban || molindone || 20-100 ||= II ||= I ||= II ||
 * Navane || thiothixene || 5-30 ||= I ||= I ||= III ||
 * Orap || pimozide || 1-10 ||= I ||= I ||= III ||
 * Prolixin || fluphenazine || 2-20 ||= I ||= I ||= III ||
 * Prolixin Decanoate || fluphenazine decanoate || 25-50mg/ 2wks ||= I ||= I ||= II ||
 * Serentil || mesoridazine || 50-400 ||= III ||= III ||= I ||
 * Stelazine || trifluoperazine || 5-30 ||= I ||= I ||= III ||
 * Thorazine || chlorpromazine || 200-600 ||= III ||= III ||= II ||
 * Trilafon || perphenazine || 8-64 ||= II ||= I ||= II ||

I Minimal, II Moderate, III Significant EPS- Extra-pyramidal symptoms: various movement disorders such as akinesia (inability to initiate movement) or akathisia (inability to remain motionless).


 * Benefits of Atypical Antipsychotics vs. Typical Antipsychotics **
 * Less extra-pyramidal symptoms
 * Minimal amount of positive symptoms (symptoms that create distortion or an excess in the individual’s regular functioning: delusions, hallucinations, etc.)
 * Minimal amount of negative symptoms (symptoms that attribute to a decrease in regular functioning: restrictions in range of emotional expression, restrictions in expression of thoughts and speech, etc.)
 * Improved cognition
 * Improved mood

(Peters-Strickland & Sincola, 2012)

__ Risperidone: __ shows a correlation between an increase in extra-pyramidal symptoms and dosage prescribed especially in doses greater than 6mg. The prolactin levels in an individual taking risperidone may also increase (//prolactin is a hormone that is secreted by the pituitary gland which increases when dopamine is blocked or suppressed.//) __ Olanzepine: __ increased doses can cause akathisia, Parkinsonism, weight gain and moderate prolactin increase. __ Aripiprazole: __ can cause weight gain and adverse effects on lipid metabolism if used in conjunction with olanzepine. __ Ziprasidone: __ less likely to cause weight gain and increase prolactin level but may cause an increase in anticholinergic effects (blockage of acetycholine in Central Nervous System and Peripheral Nervous System). __ Quetiapine: __ is likely to cause weight gain but can be used as an alternative for patients who have to switch medications due to severe weight gain and high cholesterol levels from other antipsychotic medications. Quetiapine is known to be helpful as a sedating agent however have a high dependence liability. __ Clozapine: __ results in the most weight gain and sedation out of all antipsychotic medications. This medication requires weekly blood monitoring and a higher level of supervision. (Peters-Strickland & Sincola, 2012)
 * Side Effects **

Due to the complex nature of psychosis and the variety of treatment options available, here is a typical step-by-step treatment protocol:
 * Treatment Protocol: **

// Step 1: // Many prescribing professionals suggest beginning treatment with risperidone (Risperdal) or paliperidone (Invega) because they are considered to be most effective in treating psychosis and other psychotic behaviours. // Step 2: // If the patient cannot tolerate risperidone or paliperidone due to side effects or if the patient is not responding to this treatment, the clinician should consider trying a couple of atypical antipsychotic medications before moving onto typical or conventional antipsychotic medications. The next best options include olanzepine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon) and aripiprazole (Abilify). // Step 3: // This stage will vary from clinician to clinician as some may prefer to continue to stick to atypical antipsychotic medications such as recommending clozapine (Clozaril). Others may prefer to try a typical antipsychotic such as haloperidol (Haldol) or thiothixene (Navane). // Step 4: // Long-lasting atypical antipsychotics may be another option such as Haldol Decanoate or Prolixin Decanoate. Injectable long-lasting medications are another option which could include Risperdal Consta, Invega Sustenna and Zyprexa Relprevv.


 * Significant Issues to Consider: **
 * Adequate doses of the medication need to be prescribed. The adequate dose can usually be found on the package labelling.
 * Each medication requires different doses due to the varying potencies between each medication.
 * Doses may be higher for those with a chronic psychotic condition/chronic psychosis versus individuals with first episode psychosis.
 * The relationship between certain patient characteristics and necessary dose adjustments need to be considered
 * § Smoking can reduce plasma levels of some antipsychotic medications
 * § Ethniticity, age, sex and other medical conditions need to be considered (ex: geriatric patients tend to be more sensitive to antipsychotic medications and metabolize them more slowly so lower dosages are more effective).
 * The patient’s response to these medications is often delayed so an adequate treatment trial is crucial.
 * § Is recommended to wait a minimum of three weeks and a maximum of six weeks before making any alterations in the treatment regimen.
 * § Some may wait longer than six weeks if the patient is showing a partial response to the medication especially if this is a subsequent trial.


 * When switching antipsychotic medications, it is better to cross-titrate rather than overlap the medications or taper them. (//Cross-titration refers to tapering the dose of the original medication while gradually increasing the new medication.//)

(Peters-Strickland & Sincola, 2012)