Medications for schizophrenia

Antipsychotics mainly reduce abnormal perceptions such as delusions and hearing voices, and they help reduce agitation too. They have less of an effect on – but can also improve – symptoms such as depression, lack of drive, and concentration and memory problems.

Various studies have shown that the symptoms improve within six weeks in

• about 30 out of 100 people who take a placebo (fake drug) and
• about 50 out of 100 people who take antipsychotics.

In other words, antipsychotics reduced the symptoms of acute psychosis within six weeks in about 20 out of 100 people. Some people also said that their quality of life had improved and they were able to return to their normal daily life sooner.

It often takes a while for the medication to start working: In many cases it already has a noticeable effect within a few hours or days, but it can sometimes take several weeks instead. If the symptoms don’t improve within two to four weeks despite taking a higher dose, it’s unlikely that the medication will start working after that. Then a different drug should be tried out.

The effectiveness of antipsychotics depends on a number of factors and varies from person to person. The following factors may play a role:

• Whether it's the person’s first episode of acute psychosis, or whether they have already had episodes in the past
• The type and severity of the symptoms
• The exact drug and dose used

Several studies have shown that relapses occurred within one year in

• about 61 out of 100 people who took a placebo (fake drug) and
• about 23 out of 100 people who took antipsychotics.

In other words, antipsychotics prevented relapses in about 38 out of 100 people. They also didn't have to go to the hospital for treatment as often.

How long someone uses the medication for will depend on things like how many acute psychotic episodes they have already had and how severe the episodes were. Treatment with antipsychotics shouldn't be stopped suddenly because that can increase the risk of a relapse. So it’s important to talk to the doctor about the best way to come off the medication.

The possible side effects of antipsychotics are:

• Abnormal motor behavior (shakiness, muscle stiffness, decreased movement)
• Involuntary movements like smacking your lips, making faces and moving your head
• Trouble swallowing
• Metabolic problems
• Restlessness
• Weight gain
• Higher risk of diabetes
• Dry mouth
• Difficulty peeing
• Impaired vision (for example, blurred vision)
• Dizziness and headache
• Tiredness and lack of drive

In rare cases, people may have an irregular heartbeat or serious blood-cell-production problems. Regular blood tests are done for this reason.

Some types of abnormal movement only develop after the medication has been taken for a long time, sometimes even years. In that case, it often lasts for a long time and is difficult to treat.

Which side effects you have (if any) depends on the active ingredient in the medication and the dosage.

There is not enough research on the effects of taking antipsychotic medications for a long time. It is thought that taking them for many years may lead to changes in some areas of the brain. The consequences of these changes are not yet clear, though.

There are different types of antipsychotic medications:

• Typical antipsychotics (first generation)
• Atypical antipsychotics (second generation)

They affect different nerve cells in the brain, but they are similarly effective in reducing the symptoms of schizophrenia. Their key differences:

• Typical antipsychotics are more likely to cause abnormal motor behavior (movements).
• Atypical antipsychotics are more likely to cause weight gain and metabolic problems.
• Some atypical antipsychotics are a little better at reducing lack of drive and concentration problems.

Sometimes the differences depend more on the specific active ingredient in the medication rather than the group it belongs to. It is not completely clear how important these differences are, and it's still a matter of debate.

"Typical" antipsychotics are further divided into two groups described as high-potency and low-potency. Both groups are similarly effective, but they differ in the dosages used and their potential side effects:

• Lower doses of high-potency antipsychotics have the same effect as higher doses of low-potency antipsychotics. But high-potency antipsychotics are more likely to cause abnormal motor behavior (muscle stiffness, trembling, fidgeting) and involuntary movements (chewing, lip-smacking, head movements).
• Low-potency antipsychotics tend to make you tired and have a calming effect. They also tend to cause problems affecting the vegetative nervous system, with a dry mouth and digestive problems.

There are no general rules to say which medication is most suitable in a particular situation. Different doctors might recommend different medications. One reason for this is because most studies haven't found any major differences between the medications in terms of their effectiveness.

It is always important to check how somebody responds to a medication, anyway. The goal is to find the most effective dose with the fewest side effects. If a medication isn't effective enough, it’s possible to increase the dose or switch to a medication with a different active ingredient.

Most people start on a low dose and then gradually increase it. Sometimes a high dose is used from the start to quickly reduce the symptoms of acute psychosis.

Different medications are often combined. But it’s not clear whether this has any advantages – especially because the risk of drug-drug interactions increases with each additional medication.

Antipsychotic medications can reduce the symptoms and consequences of schizophrenia. But their side effects can be unpleasant, and not everyone needs to take them. So it’s important to carefully weigh their pros and cons before making a decision. The following factors play a role:

• What is the goal of treatment?
• How bad are the symptoms?
• What phase of the disease is to be treated?
• What are the potential consequences of having another episode of acute psychosis?
• What would switching medications do?
• What would happen without medication?
• How serious are the side effects?
• Can the dose be adjusted to make the side effects tolerable?
• How effective were previous treatments?
• What are the other treatment and support options?

Even if medications reduce acute psychotic symptoms and prevent relapses, that might not always be the main treatment goal. It is also important to consider how much the person and their relatives or friends are suffering from – or at risk due to – the symptoms and their consequences.

In acute psychosis, doctors usually consider treatment with antipsychotic medications to be necessary. But if the symptoms are mild, medications might not be needed, or very low doses might be used. This may also be the case if the effects of a psychotic episode are limited and the person has good support from others during this time. The same is true if a relapse is unlikely – although it’s impossible to reliably predict relapses.

It is important that people with schizophrenia are involved in the planning of their treatment and that their wishes are respected. But that’s often not the case, and it can be difficult to do in an acute phase. It may be easier once the acute symptoms have improved. After some time has passed, you can discuss whether the treatment with medication can be stopped at some point or whether it might be better to continue taking it over the long term.

In order to make an informed decision together with doctors, you have to be fully informed about the consequences of taking the medications. This information also helps when defining personal treatment goals.