The prognosis for many patients is improved by the long term use of anti-psychotic medication either orally or in depot preparations (e.g. fluphenazine decanoate or flupenthixol i.m. every 3-4 weeks). Depot injections are particularly useful when compliance problems are likely.
Patients returning to an unsatisfactory family setting are in particular need of long term drug treatment
- half- life of fluphenazine is longer than that of flupenthixol so fluphenazine might be better with non-compliant patients or where the dosage interval has, for some reason, to be greater than for 4 weeks. On the other hand flupenthixol may be better for patients with prominent depressive symptoms. Individual requirement in dose of depot neuroleptic varies greatly, and some patients can be maintained on lower than standard doses
NICE (1) have produced a schizophrenia guideline:
- NICE in 2002 (2) stated that atypical antipsychotic medication should be used in preference over typical antipsychotics but no longer make that assertion (1)
- the decision on which antipsychotic to use should be done in partnership with the service user, and carer if appropriate.
- when deciding on the most suitable medication, consider the relative potential of individual antipsychotics to cause extrapyramidal side effects (such as akathisia), metabolic side effects (such as weight gain), and other side effects (including unpleasant subjective experiences)
- regular combined antipsychotic medication should not be started, except for short periods (for example, when changing medication)
- before starting antipsychotics an electrocardiogram (ECG) should be offered if:
- specified in the summary of product characteristics (SPC)
- physical examination shows specific cardiovascular risk (such as diagnosis of high blood pressure)
- there is personal history of cardiovascular disease, or
- the service user is being admitted as an inpatient
- when using antipsychotic medication then consider treatment with antipsychotic medication as an individual therapeutic trial:
- record the indications, expected benefits and risks, and expected time for a change in symptoms and for side effects to occur
- start with a dose at the lower end of the licensed range and titrate upwards slowly within the dose range in the British National Formulary (BNF) or SPC
- justify and record reasons for dosages outside the range specified in the BNF or SPC
- monitor and record the following regularly and systematically throughout treatment, but especially during titration:
- efficacy, including changes in symptoms and behaviour
- side effects of treatment, taking into account overlap with some of the clinical features of schizophrenia
- adherence
- physical health
- the rationale for continuing, changing or stopping medication and the effects of such changes should be recorded
- carry out a trial of the medication at optimum dosage for 4-6 weeks
- withdrawing/stopping medication
- inform service users about the high risk of relapse if medication is stopped in 1-2 years
- if withdrawing antipsychotic medication, do this gradually. Regularly monitor for signs and symptoms of relapse for at least 2 years after withdrawal
- depot/long-acting injectable antipsychotics should be considered when:
- service users would prefer this after an acute episode
- avoiding covert non-adherence to medication is a clinical priority
- inadequate response to treatment and use of clozapine
- clozapine should be be used if symptoms have not responded adequately despite sequential use of at least two different antipsychotics, one of which should be a non-clozapine second-generation antipsychotic
- if symptoms have not responded adequately to an optimised dose of clozapine, review the diagnosis, adherence to treatment, engagement with and use of psychological treatments, other possible causes of non-response and measure therapeutic drug levels before offering a second antipsychotic to augment clozapine. The second drug should not compound the common side effects of clozapine. An adequate trial of augmentation may need to be up to 8-10 weeks
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