Antipsychotic drugs psychotic symptoms

Behavioral changes may also occur with the use of the antipsychotic drugs. These changes include an increase in the intensity of the psychotic symptoms, lethargy, hyperactivity, paranoid reactions, agitation, and confusion. A... 

Antipsychotic medications, previously referred to as major tranquilizers or neuroleptics, are effective for the treatment of a variety of psychotic symptoms—such as hallucinations, delusions, and thought disorders—regardless of etiology. The term major tranquilizer is a misnomer because sedation is generally a side effect, and not the principal treatment effect. Similarly, the term neuroleptic is based on the neurological side effects characteristic of older antipsychotic drugs, such as catalepsy in animals and extrapyramidal side effects (EPS) in humans. 

The most common indications for antipsychotic drugs are the treatment of acute psychosis and the maintenance of remission of psychotic symptoms in patients with schizophrenia. More recently, the atypical antipsychotics have become part of the standard repertoire for the treatment of bipolar disorder, as discussed in Chapter 5. Antipsychotic drugs also ameliorate psychotic symptoms associated... 

Antipsychotics are a chemically diverse group of drugs having in common the ability to ameliorate psychotic symptoms. Unfortunately, a significant percentage of patients fail to respond adequately or may develop adverse effects such as acute EPS, various tardive syndromes (e.g., TD, dystonia, etc.), and, less commonly, even more serious adverse events such as NMS and agranulocytosis. 

When psychotic symptoms are present, use of a combination of antidepressant plus antipsychotic or a trial with ECT Certain clinical variables are also helpful in choosing a drug for an initial trial, including the following ... 

One consistent finding has been that patients with psychotic depression treated with antidepressant monotherapy or even the combination of an antidepressant plus antipsychotic have a lower response rate than those depressed patients without psychotic symptoms (45). Although evidence supports an improved response when these patients undergo treatment with ECT, this apparent superiority may be related to a selection bias ( 46). Thus, it may be that patients with psychotic depression are more likely to receive ECT earlier in their course of illness and therefore the extent of their true drug resistance is unknown ( 1). 

Younger patients with schizophrenia may be less responsive to pharmacotherapy than adult patients ( 164, 165). Nonresponse to typical antipsychotics is as high as 40% to 50% in some reports. Thought disorder is the most drug-refractory of the classic psychotic symptoms in children and adolescents with schizophrenia. Thus, even when the more florid symptoms (e.g., hallucinations and delusions) abate following treatment with antipsychotics, these patients frequently continue to have substantial impairment in social functioning and scholastic performance. 

Nonpsychotic persons also experience impaired performance as judged by a number of psychomotor and psychometric tests. Psychotic individuals, however, may actually show improvement in their performance as the psychosis is alleviated. The ability of the atypical antipsychotic drugs to improve some domains of cognition in patients with schizophrenia and bipolar disorder is controversial. Some individuals experience marked improvement and for that reason, cognition should be assessed in all patients with schizophrenia and a trial of an atypical agent considered, even if positive symptoms are well controlled by typical agents. 

For approximately 70% of patients with schizophrenia, and probably for a similar proportion of patients with bipolar disorder with psychotic features, typical and atypical antipsychotic drugs are of equal efficacy for treating positive symptoms. However, the evidence favors atypical drugs for benefit for negative symptoms and cognition, for diminished risk of tardivedyskinesia and other forms of EPS, and for lesser increases in prolactin levels. 

Profound mood-stabilizing effects of the atypical antipsychotic drugs were observed once their antipsychotic effects were documented. These effects on mood appear to be quite independent of their effects on positive symptoms of psychosis. The most dramatic story may be how impressive the atypical antipsychotics are turning out to be for the treatment of bipolar disorder (Fig. 11 — 53). Although the best documented effect of these drugs is to reduce psychotic symptoms in the acute manic phase of bipolar disorder, it is clear that these agents also stabilize mood and can help in some of the most difficult cases, such as those marked by rapid cycling and mixed simultaneous manic-depressed states that are often nonresponsive to mood... 

---