精神疾病急性期治疗

Short-term treatment with antipsychotics

1  The primary aim is to reduce the most serious symptoms, including hallucinations, delusions, agitation and disorganised thought and behaviour.

2  Antipsychotic agents are the primary medication for schizophrenia and related psychotic disorders. These agents are particularly effective against psychotic symptoms, while their impact on residual symptoms (lack of interest and initiative, blunted affect) is modest or absent.    江西省精神病医院精神科朱健民

3  Before starting antipsychotic therapy, it is generally recommended to check weight and blood pressure. Other suggested monitoring includes electrocardiogram (mandatory in some countries for specific antipsychotics, for example haloperidol), full blood count, urea and electrolytes, creatinine phosphokinase, liver function tests, blood glucose,

lipid pattern and prolactin. If these laboratory examinations are not feasible, health care providers should ask the patient and/or family member about the existence of cardiovascular, renal or hepatic abnormalities, and whether drug therapies for these medical conditions have been prescribed and taken.

4  In clozapine users, before starting treatment, obligatory monitoring in many countries includes full blood count. If full blood count is not feasible, clozapine should not be prescribed.

5  In clinical practice antipsychotic agents are classified into conventional or first-generation antipsychotics and atypical or second-generation antipsychotics. First-generation antipsychotics are classified into phenothiazines (chlorpromazine, levomepromazine,  promazine, pericyazine, pipotiazine, fluphenazine, perphenazine, prochlorperazine and trifluoperazine), butyrophenones (benperidol and haloperidol), diphenylbutylpiperidines (pimozide), thioxantenes (flupentixol and zuclopentixol) and the substituted benzamides (sulpiride). Second-generation antipsychotics include amisulpride, aripiprazole, clozapine, olanzapine, risperidone, quetiapine, sertindole, ziprasidone, zotepine.

 6  With the exception of clozapine (which is more effective than first-generation antipsychotics in the pharmacological treatment of refractory schizophrenia), first- and secondgeneration antipsychotics are similarly effective in the acute treatment of psychotic symptoms. However, these two groups of agents markedly differ in terms of adverse

effects. 

7  According to the WHO EML, essential medicines for psychotic disorders are chlorpromazine, fluphenazine decanoate or enantate, haloperidol. These medicines are indicated as an example of the class for which there is the best evidence for effectiveness and safety. Thus chlorpromazine represents phenothiazines; fluphenazine represents inject-

able long-acting antipsychotics; haloperidol represents butyrophenones.

8  In patients with acute phase schizophrenia or other primary psychotic disorders health care providers should consider the prescription of an oral antipsychotic. If more than one antipsychotic is available, health care providers should chose the most suitable agent for each patient taking into consideration the following aspects: 1) Inclusion in

the WHO EML: this list includes the most efficacious, safe and cost-effective medicines; 2) Past history of antipsychotic responsiveness: if a patient has already responded well, without intolerable side-effects to a specific agent, that agent might be chosen; if a patient failed to respond, or had intolerable side-effects, to a specific agent, that agent should generally not be prescribed any more; 3) Treatment adherence: if treatment  adherence is a problem, physicians should consider long-acting preparations, such as fluphenazine decanoate; 4) Medical comorbidities: if a patient suffers from specific medical problems, some agents should be avoided (e.g. thioridazine should be avoided in elderly patients with electrocardiogram abnormalities, olanzapine and clozapine

should be cautiously prescribed to patients with glucose abnormalities); 5) The subjective impact of adverse reactions: health care providers should discuss with the patient and/or family member the plausible impact of side-effects (e.g. the relevance of weight gain may vary between males and females and in different age groups or cultures); 6) Cost implications: these may change according to the health care system in which antipsychotics are prescribed; 7) New/old agent: as a general rule, it is wise to prescribe well known medicines, since the side-effect profile of new medicines becomes clear only after years of marketing.

9 Treatment should be regularly monitored, and its effect should be assessed after 6-8 weeks. If no improvement is seen after 8 weeks, health care providers may discuss with the patient and/or family member the possibility to switch to another oral antipsychotic. If treatment adherence is a major problem, health care providers may discuss with the patient and/or family member the possibility to switch to a long-acting preparation.If adverse reactions are a major problem, health care providers may discuss with the patient and/or family member the possibility to decrease the dose. If adverse reactions persist despite a dose reduction, a switch to another antipsychotic may be considered.

10  Health care providers should not consider clozapine as first-line pharmacological treatment, as it may cause life-threatening adverse effects of which agranulocytosis is the best known (See 5.6 and 5.7).

11  For prompt control of acute psychotic symptoms health care providers should consider intramuscular treatment only if oral treatment is not feasible. According to the WHO EML, essential medicines are chlorpromazine injection (e.g. 25 mg intramuscular) or haloperidol injection (e.g. 5 mg intramuscular). After intramuscular antipsychotic ad-

ministration, health care providers should monitor blood pressure, pulse, body temperature and respiratory rate.

12 In addition to pharmacological and non-pharmacological interventions, health care providers should provide information to patients and family members, emphatic listening, reassurance and psychological support. This may help develop a good relationship and a therapeutic alliance that may positively influence the patient subjective well-being and the long-term outcome of the disorder.

13  During antipsychotic treatment, health care providers should check whether neurologic side-effects have developed, including muscular rigidity, tremor, muscular spasm, abnormal involuntary movements of tongue, mouth and face. Health care providers should additionally check weight and blood pressure. Other suggested monitoring includes electrocardiogram (mandatory in some countries for specific antipsychotics, for example haloperidol), full blood count, urea and electrolytes, creatinine phosphokinase, liver function tests, blood glucose, lipid pattern and prolactin. If these laboratory tests are not feasible, health care providers should remember to regularly make a medical examination, including a recent medical history that may help recognize symptoms suggesting the development of cardiovascular, renal or hepatic abnormalities.