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There are two main avenues of treatment for schizophrenia:

• Drug therapy
• Psychosocial therapy

Drug Therapy

Antipsychotics are considered the first line treatment for schizophrenia since they can eliminate or reduce positive (psychotic) symptoms quickly. Antipsychotics have been used since the mid 1950's. There are two types of antipsychotics:

• Typical antipsychotics
• Atypical antipsychotics

Typical Antipsychotics

Typical antipsychotics include:

• Chlorpromazine (Thorazine)
• Haloperidol (Haldol)
• Perphenazine (Etrafon)
• Fluphenazine (Prolixin)

Typical antipsychotics (also known as first generation antipsychotics) are effective for reducing positive symptoms in schizophrenia. Side effects include:

• Severe extrapyramidal symptoms (motor system involved in the coordination of movement) including tardive dyskinesia (involuntary, repetitive, purposeless movements), rigidity, muscle spasm, tremors, and restlessness
• Studies are underway to investigate whether first generation antipsychotics may increase the rate of depressive symptoms in schizophrenic patients
• Erectile dysfunction (occurs in 23-54% of men)
• Ejaculatory disturbances
• Loss of libido in men and women

Atypical Antipsychotics

Atypical antipsychotics include:

• Clozapine (Clozaril)
• Risperidone (Risperdal)
• Olanzapine (Zyprexa)
• Quetiapine (Seroquel)
• Ziprasidone (Geodon)
• Aripiprazole (Abilify)

Atypical antipsychotics are also known as second generation antipsychotics and have been used since the 1990s. They, too, are effective for positive symptoms and in addition, unlike typical antipsychotics, they appear to have a positive effect on cognitive deficit and may also limit progression of negative and depressive symptoms. They are, however, considerably more expensive than the older antipsychotics.

Adverse reactions to atypical antipsychotics may include:

• Weight gain
• Metabolic changes associated with elevated risk of diabetes and high cholesterol
• Drowsiness
• Dizziness when changing positions (sitting/standing)
• Rapid heartbeat
• Blurred vision
• Sensitivity to the sun
• Menstrual changes
• Agranulocytosis (low of white blood cell count) - this is a significant side effect associated only with clozapine and any patient taking clozapine must have their white blood count monitored every 1-2 weeks
• Reduced sexual interest and function in men and women taking clozapine but to a lesser extent than with first-generation antipsychotics

Clozapine is very effective for treatment of psychotic symptoms (including residual or persistent psychotic symptoms), negative symptoms, and suicidality but because of the risk of its significant side effects, and because of the need to have frequent blood tests it is usually considered a drug of choice only for patients who are nonresponsive to other medications.

When the appropriate antipsychotic medication and dose is determined, agitation and hallucinations may improve within days while an improvement in delusions may take a few weeks. By the sixth week of being medicated, the patient typically notices a significant improvement in positive symptoms.

A large study called CATIE (Clinical Antipsychotic Trial of Intervention Effectiveness) was initiated by the National Institute of Mental Health and the results were published in December 2006. As part of this study, researchers investigated the efficacy of older vs. newer antipsychotics drugs. The results indicated that perphenazine, an older antipsychotic, was as effective as the newer antipsychotics. In addition, the study found that total monthly health costs (medical costs plus inpatient/outpatient expenses) were up to 30% lower for patients taking perphenazine.

One of the drawbacks of the study was that the 18 month period investigated was not long enough to evaluate the long-term side effects of perphenazine, such as tardive dyskinesia, diabetes, or cardiovascular problems. Even so, a conclusion of the study was that physicians should consider the older antipsychotic, perphenazine, as a first-line treatment for schizophrenia. There are several other issues currently under investigation in the CATIE study.

Psychosocial Therapy