CURESZ.ORG Schizophrenia Treatment Issues: What to Discuss With Your Doctor The CURESZ Foundation

Learning about Schizophrenia

Schizophrenia is a treatable brain illness ranging from mild to severe. It is very diverse in its causes, symptom severity and outcome similar to the diversity among different types of Parkinson’s Disease or cancer. Persons with schizophrenia may have some similar features, but also different experiences.

For persons with schizophrenia, understanding and learning about the illness itself is vital. Therefore, consider investing some time learning about the biology and clinical aspects of the disease, and ask your psychiatrist and treatment team all the questions you can think of.

Over the past 50 years, the medical care of schizophrenia has shifted from an inpatient institutional setting to community-based care, except when a psychotic relapse occurs when hospitalization is necessary. Today, many, but not all, people with schizophrenia, can achieve significant improvement in their illness and can return to vocational and social functioning, especially with the help of injectable antipsychotic medications, which protect against relapse better than pills. Sometimes, other medications like antidepressants or anti-anxiety medications may also be needed.

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Setting Goals with your Treatment Team

You should ask your psychiatrist to explain the illness and the various available treatments (including pills or intramuscular injections once every 1-3 months without having to take any pills) and assure you that all available treatments will be tried until you have achieved a return to your baseline. For about 25% of patients whose psychosis does not respond to the standard drug therapies, a medication called clozapine may be necessary (see below, clozapine can eliminate hallucinations or delusions 50% of the time when other antipsychotics fail). Once you start improving, your doctor and the mental health team should work with you to establish goals for the future, such as returning to school or work, spending more quality time with family and friends, and engaging in hobbies and other meaningful activities.

Recovery, not continued illness and disability, should be the goal for most patients who suffer from schizophrenia.

Long- Acting Injectable Antipsychotic Medications

Memory difficulties are common in schizophrenia and may play a role in forgetting to take daily medications (or monthly injections) that are vital to prevent the recurrence of psychotic episodes. Several injectable medications have been available for many years, which eliminate the need to take pills every day. Some injections work for two weeks, others can be given monthly, while some may work for six weeks, two months, or even for three months. These include injectable forms of risperidone (Risperdal Consta every 2 weeks and risperidone Perseris once a month), paliperidone (Invega Sustenna, which is monthly, and Invega Trinza, every 3 months), monthly aripiprazole (Abilify Maintena), injections every 4, 6 or 8 weeks with aripiprazole lauroxil (Aristada), and once a month injections of olanzapine (Relprevv).

Ask your doctor about these injectables. They are an excellent alternative to daily pills. Avoiding recurrence of psychosis is critical to avoid brain damage and treatment resistance.

Vitamins and Supplements

Studies show that several supplements added to antipsychotic medications during the acute episodes of psychosis may help in schizophrenia. These include Omega 3 fatty acid (which may counteract the brain inflammation during psychosis), N-Acetyl Cysteine (which may help neutralize the harmful free radicals during psychosis), and vitamin D (which is important for brain development and ongoing health).

Omega 3 fatty acids (The Anti-Inflammatory Supplement Fish Oil) Fish oil may help when added to the antipsychotic medication in early phases of psychosis When brain inflammation can occur. Fish oil is relatively cheap, and has few side effects. You can find it at any drug store.

Fish oil contains an omega-3 fatty acid called DHA (docosahexaenoic acid) which may promote brain health. Consider talking to your doctor about a prescription for the more expensive, purified form.

The Antioxidant Supplement N-Acetyl Cysteine (NAC) N-acetyl cysteine is a strong antioxidant and some studies suggest it may help neutralize the harmful effects of elevated levels of free radicals, which are known to occur during psychosis. People with schizophrenia have been found not to make enough antioxidant in their cells (like glutathione) to fight free radicals, and NAC helps increase glutathione levels. More research is being done on this supplement.

Vitamin D3 Exposure to sunlight prompts the body to manufacture vitamin D which is important for brain health in schizophrenia, depression and even multiple sclerosis. It is especially important for pregnant women to have normal blood level of vitamin D3 to ensure normal brain development in their babies. Very low levels of vitamin D3 during pregnancy have been reported to increase the risk of developing schizophrenia in adolescence or early adulthood.

Cognitive Behavioral Therapy (CBT) as Adjunctive Therapy

Since the 1990s, research has proven the effectiveness of CBT in depression and anxiety, and for some symptoms of schizophrenia. It is considered one of the most effective psychotherapy methods.

Clozapine Can Work if Other Antipsychotics Fail

Clozapine is considered the “last resort” medication in schizophrenia because it can work when other antipsychotic medications fail to reduce persistent hallucinations or delusions. (These cases are called “treatment resistant” or “refractory” cases).

Clozapine is associated with some side-effects. It can cause a reduction in white blood cell count in very rare cases (less than 1%). That’s why weekly white blood cells have to be measured with a quick blood test. Clozapine also may cause increased appetite and weight gain, sleepiness, constipation and increased salivation. In high doses, it may cause other problems, such as diabetes or seizures but most people do not need high doses.

Because patients on clozapine must be monitored for side effects, some psychiatrists avoid using clozapine, or use it rarely. In the U.S., while 25% of patients may benefit from a trial of clozapine, less than 5% actually receive it from their psychiatrist and may need to be referred to a clozapine expert.

All patients who have not achieved full remission with two different antipsychotic drugs -- which means they are asymptomatic or nearly free of delusions or hallucinations -- deserve a trial of clozapine.

Diet and Exercise

Several studies show the benefit of exercise (walking 30 minutes a day) to help lose weight and improve cardiac health, and also to stimulate the production of new brain cells. Studies also show the benefit of a healthy diet (low calorie and low fat, with fiber from fruits, vegetables and nuts) to avoid weight gain and reduce the risk of diabetes and high blood pressure, which are very common in schizophrenia.

CAUTION! Discontinuing Psychiatric Medications Can Lead to Psychotic Relapses

When your doctor prescribes a medication, ask what you should do if an intolerable side effect occurs. If you are experiencing side effects from your medication, do not stop your medications abruptly, but get in touch with your doctor right away. The muscle stiffness can improve with a modest reduction of the dose. Discontinuing medications can lead to psychotic relapses, and in some cases, it can cause withdrawal symptoms like insomnia or agitation or muscle twitching. Additionally, psychiatric medications become less effective after each recurrence.

There are twelve new generation antipsychotic medications available today. If you are experiencing side effects, know that there may be another medication that may suit you better. Every person’s experience with medication is different because our bodies are biologically different.

Tardive Dyskinesia as a Side Effect of Antipsychotics

Tardive Dyskinesia (TD) is an involuntary movement disorder which is a serious neurological side effect of all antipsychotic medications, but especially older (and harsher) antipsychotics drugs like haloperidol. TD's movements are often seen in the face, including the tongue lips, jaw and eye blinking/grimacing but can also affect the neck, trunk, arms, fingers, legs, toes or diaphragm.

Fortunately, two effective medications were recently approved by the FDA. Valbenazine was approved by the FDA in April 2017, and deutetrabenazine was subsequently approved in August 2017. These medications can significantly reduce or eliminate TD movements.

Because the older antipsychotics like haloperidol are much more likely to cause acute muscle stiffness, tremor, rigidity or restlessness (in the first few hours or days or weeks), and a high rate of TD (usually many years of use), they should not be used to treat schizophrenia or bipolar disorder. The newer antipsychotics have a much lower rate of TD.

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