Psychotic disorders treatment

When working with the client who has schizophrenia or related psychotic disorder, treatment plan formulation and execution can be difficult as... 

Antipsychotic medications are indicated in the treatment of acute and chronic psychotic disorders. These include schizophrenia, schizoaffective disorder, and manic states occurring as part of a bipolar disorder or schizoaffective disorder. The co-adminstration of antipsychotic medication with antidepressants has also been shown to increase the remission rate of severe depressive episodes that are accompanied by psychotic symptoms. Antipsychotic medications are frequently used in the management of agitation associated with delirium, dementia, and toxic effects of both prescribed medications (e.g. L-dopa used in Parkinson s disease) and illicit dtugs (e.g. cocaine, amphetamines, andPCP). They are also indicated in the management of tics that result from Gilles de la Tourette s syndrome, and widely used to control the motor and behavioural manifestations of Huntington s disease. 

Haverkos HW, Pinsky PF, Drotman DP, etal Disease manifestation among homosexual men with acquired immunodeficiency syndrome a possible role of nitrites in Kaposi s sarcoma. Sex Transm Dis 12 203-208, 1985 Haverkos HW, Kopstein AN, Wilson H, et al Nitrite inhalants history, epidemiology, and possible links to AIDS. Environ Health Perspect 102 858-861, 1994 Hernandez-Avila CA, Ortega-Soto HA, Jasso A, et al Treatment of inhalant-induced psychotic disorder with carbamazepine versus haloperidol. Psychiatr Serv49 812— 815, 1998... 

Grainger DL, Hamilton SH, Genduso LA, et al (1998a). Medical resource use and work and social outcomes for olanzapine compared with haloperidol in the treatment of schizophrenia and other psychotic disorders. Poster presented at the 21st Congress of the CINP, Gla ow, July 1998. 

Daumit et al. (2003) conducted a series of cross-sectional analyses of outpatient physician visits from 1992-2000 where antipsychotics were prescribed. The data was collected from the National Hospital Ambulatory Medical Care Survey conducted by the National Center for Health Statistics. African Americans had half the odds of receiving an SGA and Hispanics had 40% of the odds, compared with Whites in the early 1990s. During 1998-2000, the frequency of SGA use for non-psychotic disorders in African Americans was equivalent to Whites but still 25% lower when patients were receiving treatment for a psychotic disorder. The use of SGAs in Hispanics increased and was equal to that of Whites in the late 1990s for all psychiatric diagnoses. 

When is medication indicated in the treatment of psychiatric illness There is no short answer to this question. At one end of the continuum, patients with schizophrenia and other psychotic disorders, bipolar disorder, and severe major depressive disorder should always be considered candidates for pharmacotherapy, and neglecting to use medication, or at least discuss the use of medication with these patients, fails to adhere to the current standard of mental health care. Less severe depressive disorders, many anxiety disorders, and binge eating disorders can respond to psychotherapy and/or pharmacotherapy, and different therapies can target distinct symptom complexes in these situations. Finally, at the opposite end of the spectrum, adjustment disorders, specific phobias, or grief reactions should generally be treated with psychotherapy alone. 

When brief psychotic disorder is diagnosed, treatment with antipsychotic medication and supportive therapy should be instituted. During treatment, however, the patient should be frequently reassessed for the presence of a mood disorder that was not easily recognizable in the initial agitated and psychotic state. 

Atypical Antipsychotics. The so-called atypical antipsychotics have revolutionized the treatment of schizophrenia and other psychotic disorders since their introduction in the 1990s. Similarly, they are replacing the older antipsychotics in the treatment of BPAD as well. They offer a similar degree of antimanic efficacy without a lessened long-term risk of tardive dyskinesia. For more information regarding the atypical antipsychotics, please refer to Chapter 4 Schizophrenia. 

Delusional Disorder and Schizotypal Personality Disorder. In onr experience, patients with BPD at times resemble those with Clnster A personality disorders or those with an Axis 1 psychotic disorder. Psychotic symptoms in the BPD patient, although intense, tend to arise in the context of some stressor and to be relatively short-lived. This usually takes the form of a brief psychotic disorder. Placing the BPD patient in a structured and supportive environment usually hastens the resolution of these psychotic symptoms. By contrast, the psychotic symptoms of a patient with a delusional disorder or a Cluster A personality disorder are long-term and potentially intractable even with antipsychotic treatment. 

Probably the greatest advances in psychiatric medications of the last 15 years have involved the neurotransmitter serotonin. First was the arrival of serotonin-specific antidepressants with fewer side effects and greater safety than their predecessors. More recently, atypical antipsychotics have highlighted the importance of serotonin-dopamine interactions in the optimal treatment of schizophrenia and other psychotic disorders. While these are indeed significant advances, medications that alter serotonin activity are not without their own side effect burden. 

Psychotic disorders - For the treatment of schizophrenia (tablets) management of manifestations of psychotic disorders (oral concentrate). 

Psychotic disorder- For the treatment of psychotic disorders (eg, schizophrenia). Haloperidol decanoate is for patients who require prolonged parenteral antipsychotic therapy. 

Unlabeled Uses Treatment of alcohol withdrawal, diabetes insipidus, neurogenic pain, psychotic disorders... 

Drugs that are marketed for the treatment of psychotic disorders in adults, the antipsychotics, are prescribed for a range of problems in children and adolescents. At present, 15 medications are marketed as antipsychotics in the United States. These agents come from several different classes of chemical compounds (Table 26.1). 

Typical (classical) antipsychotics have been proposed for a wide range of disorders. In the context of EOS the following indications exist acute treatment, maintenance treatment, and relapse prevention of schizophrenic disorders acute treatment and maintenance treatment of schizoaffective disorders treatment of organic mental disorders with psychotic features and... 

These authors also examined which medications were prescribed to patients with specific diagnoses. The majority of antidepressants were prescribed for patients with major depression, dysthymia, or bipolar disorder. Antipsychotics were prescribed frequently for conduct/oppositional disorder, psychosis, and major depression or dysthymia. In the state hospital, the proportion of nonpsychotic patients who received antipsychotic treatment depended on patients age thus, the frequency of children who were not diagnosed with a psychotic disorder but who were treated with antipsychotic medication was greater among children 12 years and younger, in contrast to children ages 13 to 18 years. 

These authors also found that 65% (New York) and 67% (Ohio) of the sampled medicated patients who received an antipsychotic prescription were not diagnosed with a psychotic disorder. Similarly, 0% and 20% of the sampled medicated patients who received a stimulant medication were not diagnosed with ADHD, and 27% and 42% of the sampled medicated patients who received antidepressants were not diagnosed with major depression, dysthymia, bipolar disorder, or related conditions. In discussing the appropriateness of the medication treatments in the survey, the authors concluded that approximately 10% of the treatments in each sample were deemed inappropriate. 

Given the available data, it is extremely important that clinicians evaluate patients with major depression for features of psychosis, because the failure to do so may result in inadequate treatment for the patient. A practical problem encountered by clinicians, however, is the subtlety of delusions. For example, it is not unusual in geriatric depression for patients to present with a somatic preoccupation that borders on delusional. These so-called near delusions may put the patient into the arena of psychotic depression. Some evidence exists that patients with depression with near delusions may respond more favorably to combinations of antidepressants and antipsychotics or ECT. Once the presence of both major depression and psychosis is determined, other psychotic disorders including bipolar disorder and schizophrenic spectrum illness must also be ruled out because this may influence long-term treatment decisions. 

Even though CPZ did not produce a permanent cure for schizophrenia (or for any other psychotic disorder), it had a dramatic impact, benefitting many as no other treatment had before (4). News of its effectiveness spread rapidly, and within 2 years, CPZ was used worldwide, altering the lives of millions of psychotic patients in a positive manner. 

---