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Treating schizophrenia can be challenging
The last resort medication, clozapine, doesn’t always work.
New study from the Treatment Response and Resistance in Psychosis Working Group on next steps for clozapine failure, or “clozapine-resistant schizophrenia”.
#1 – Try a higher dose of clozapine for at least three months. Track clozapine with blood levels.
#2 – Keeping the dose of clozapine the same, add either amisulpride or oral aripiprazole.
#3 – Keeping the dose of clozapine the same, add a 12 session course of ECT (electroconvulsive therapy).
#4 – Keeping the dose of clozapine the same, start a course of at least 15 sessions of Cognitive-Behavioral Therapy.
#5 – Keeping the dose of clozapine the same, try adding a set of psychosocial interventions.
#6 – Keeping the dose of clozapine the same, add a course of Repetitive Transcranial Magnetic Stimulation (rTMS) treatments.
If none of the above work it is time to give up on the clozapine, taper it down to a lower dose and then discontinue it, and try using other medications or treatments.
Other suggestions about what to do when clozapine doesn’t work probably have little merit at this time.
Schizophrenia is easier than ever to treat because there are so many effective medications from which to choose. But there’s one unique old medication that’s considered to be the best: clozapine. If you’re one of our paid subscribers, we have a whole article describing that it’s the best. Especially for people whose schizophrenia has not been helped by one or two other medications, clozapine has been found to be the best next medicine to try. The medical literature has many reviews offering this opinion and doctors who treat schizophrenia pretty much agree. When someone with schizophrenia can’t find any other medicine that works, try clozapine. The reason it’s not the first “go-to” medicine is that it has one rare but potentially fatal side effect. It might lower a person’s white blood cell count leaving them at risk for serious illness or death from infection.
antique glycerin suppository tin – photo by bluebudgie
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Clozapine’s Fatal Constipation – Another Known Risk
This terrible constipation clozapine side effect is more manageable than the low white cell count adverse reaction, but only if you are aware that it can happen and that it can be serious. So, whether you’re the doctor prescribing clozapine, or a person taking it, or if you know a person who takes it, you need to know about clozapine and the possibility of fatal constipation. If someone taking clozapine starts to get constipated it has to be very actively treated. The individual has to pay attention to it. In January 2020 the FDA strengthened the warning about untreated constipation in people taking clozapine because it can cause such serious, or even fatal, bowel problems. The higher the dose of clozapine taken, the higher the risk for this side effect. The risk is also increased if other medicines that cause constipation are used along with the clozapine.
The Bowel Problems That Can Lead to Hospitalization and Death
Common with clozapine are bowel side effects. If these side effects are not treated they can lead to complications that are at least super uncomfortable. It the constipation progresses it can require medical care or even require hospitalization. So if someone taking clozapine gets constipated, it has to be treated. It’s always been known that clozapine changes how the bowels work. While death from clozapine’s bowel side effects is not common, it can happen. If bowel problems on clozapine are not treated quickly, serious bowel complications can develop, like complete bowel blockage. It is in these situations that deaths have been known to happen.
What You Should Do If You’re Taking Clozapine
If you’re taking clozapine and having trouble with constipation, you have to talk to your doctor about it. Tell your doctor how moderate or bad the constipation is and all the other medicines you’re taking, including over-the-counter medicine and health supplements. Constipation means less than your usual number of bowel movements. It’s most important for you to talk with your doctor if you have less than 3 bowel movements a week, you have dry stools or hard stools, or you can’t pass gas. The common symptom with clozapine-induced constipation is severe diffuse abdominal pain. It’s even more serious if you also have nausea, bloating or belly swelling, belly pain, and/or vomiting.
How To Avoid Constipation If You’re Taking Clozapine
There are things you can do to try to prevent getting constipated on clozapine. The foods you eat are important. Try to eat more vegetables, grains, and fruits, that is, go with a high fiber diet. But, unless your doctor tells you otherwise, avoid “bulking” supplements like Metamucil or other psyllium products, and avoid fiber supplements. Make sure to drink plenty of liquids including lots of water. And start a regular exercise program. Exercise helps the bowels work better. It might be good to take a laxative, too, even before your constipation gets bad. Ask your doctor which ones are recommended.
Other Medicines That Slow the Bowels, So Don’t Take With Clozapine
(But First Ask Your Doctor)
Calcium supplements
Medicines for acid stomach that have calcium and/or aluminum in them
Antihistamines used for allergies and colds
Medicines like ibuprofen that are used for pain
Muscle relaxants
Opioids (narcotics) used for pain, like codeine and morphine
Medicines for psychosis other than clozapine
Medicines for depression, especially the “tricyclic antidepressants”
Medicines for calming the stomach and for nausea
Iron supplements
Some medicines for epilepsy like phenytoin and clonazepam
The heart rhythm and high blood pressure medicines called calcium channel blockers. For example, verapamil
Some Parkinson’s disease medicines
Medicines for urine incontinence
The New FDA Warnings Are Based on a Big FDA Review
You might wonder, why the big deal now on this topic. The red flag went up because the FDA reviewed reports dating from 2006 to 2016. During this time they found 10 cases of constipation that became serious. The serious bowel problems led to hospitalization, surgery, or death. In one case the walls of the large bowel actually just died. In another the blood supply to the bowel had completely stopped. Yet another case described that the bowel itself died, and still another had abdominal swelling that led to bowel obstruction. Some of these cases were reported to the FDA directly and others the FDA found in the medical literature. The FDA realized that there are likely many more cases that were never reported.
Example: Small Bowel Holes from Clozapine
There’s a case report from Portugal about holes that developed in the small intestine from clozapine. The individual was taking clozapine 600 mg daily. He went to the hospital Emergency Department with belly pain. The situation required an emergency abdominal surgery. At surgery the doctors saw multiple small holes in different parts of his small bowel. They had to take out 5 feet (1.5 meters) of his small bowel and part of his large bowel to save his life. He was in the hospital 28 days. He did survive and was able to go home.
Example: Death Due To Clozapine Constipation
An article in Psychosomatics describes a case report of a less fortunate individual who died as a result of clozapine constipation that got so bad it blocked his entire colon. The guy was 43 years old and had several medical problems. He was taking clozapine 750 mg a day for 6 years. He came to the hospital confused, vomiting, and blue, with a fast heart rate, fast breathing, and blood pressure so low that it could not be measured. He had a hard, inflamed belly. At surgery the surgeons found complete bowel blockage due to hard constipation. His colon was removed and he was put in ICU with maximal care. Despite this continuous close medical supervision and maximum care in the ICU he died 3 weeks later of a massive infection and the failure of several organs.
funny fancy old outhouse water closet – photo by Domainick
The FDA Does Not Want You to Avoid Clozapine – Just Be Aware and Careful of Constipation
One of the FDA’s central jobs it to warn everyone, doctors, patients, and the family and friends of patients, about any risks of medication. This FDA warning about clozapine’s fatal constipation does not mean that anyone should just stop clozapine without a discussion with their doctor. The FDA’s warning is meant to make you aware that if you’re taking clozapine and you get constipated, don’t treat it as a minor problem. Constipation when taking clozapine is an important medical condition that needs treatment, so discuss it with your doctor. Your doctor will instruct you on how to treat any mild constipation so that it never gets worse. And if the constipation does not get better no matter what you do, your doctor will help you find a different medication to take instead of clozapine.
A Reader Asked: This article is responding to a reader’s question, asking:
When Can I Get Off Treatment for Schizophrenia?
One of our Canadian readers sent in the question: “When Can I Get Off Treatment for Schizophrenia?” A great question. This question is like a gold mine with many nuggets of information waiting to be uncovered. It’s an opportunity to look at schizophrenia treatment and medication safety. Let’s explore at least a few of the possible answers.
Get Off Your Treatment for Schizophrenia Immediately?
Given that schizophrenia is a lifelong medical condition requiring medication for a lifetime, the idea of stopping one’s medication immediately might seem radical. But there are times when you need to stop it immediately (and call your doctor and/or head for the nearest hospital emergency department). There are uncommon side effects of the medicines commonly used to treat schizophrenia that are dangerous, cannot be reversed, and could be life threatening. For example, allergic reactions, heart rhythm problems (QT interval prolongation, torsades de pointes), thromboembolism, seizures, stroke, and pancreatitis. These are important and we cover them in more detail below. But if one of these side effects occurs, call your doctor immediately for advice.
Another “Get Off Your Treatment for Schizophrenia Immediately” Answer
This answer is not about medication. As with any disorder affecting the brain, it’s helpful to work with a “guide” since at times your brain is not at it’s best. This helper person might be viewed as a guide, or an educator, or a therapist or psychotherapist. Whatever you call this person, he/she is a “support person” to help you through the rough spots of life. Also, when things are good, to work with you to prepare for the next rough spot. Because that’s how we all experience life, a series of rough patches with smoother sailing in between. If this person is no help at all, or even worse, just another problem person in your life, just stop. Find a new therapist. There are many good therapists, even some great ones. Respect yourself enough to not stay with a lemon therapist thinking you can make lemonade.
When Can I Get Off Treatment for Schizophrenia? Soon!
Soon, but not today. There are medical conditions for which the person needs to take a medication for the rest of his/her life. Type 1 diabetes, for example. The patient needs insulin. Without insulin for a while, they die, as did all type 1 diabetics before 1922. Or high blood pressure. Without treatment, it might take a decade or two, but high blood pressure will kill you with a stroke or heart attack. Medication for high blood pressure is usually needed for the rest of your life. Schizophrenia is another one. You need to take the right medication forever. So you need a medication that you can take, that doesn’t make you sick, that you can tolerate. So if you’re taking a medication that you can’t tolerate or that you don’t like, that’s not going to work. Talk to your doctor.
Finding the Right Medication for the Rest of Your Life
People argue about the best exercise program to stay healthy. Some say aerobic exercise like jogging, running, or dancing. Others swear by weightlifting, like chest presses and biceps curls. Others like flexibility and balance, like yoga and tai chi. But wisdom says the best exercise is the one you will do and keep doing. The same is true of your medication for schizophrenia. The best medication, the absolutely best medication, is the one that you will take regularly and keep taking forever. To find that right medication might become hard work. It can be a challenge, it might take time and trial and error. So if you don’t like your medication, talk to your doctor about changing it. Work with her to find the best one. And, if you feel your doctor can’t work with you to do this, find a new doctor.
When Can I Get Off Treatment for Schizophrenia? Back To Stopping Your Medication Immediately
Above, when we listed the medical emergencies for which you should stop your medications immediately, we said we would cover these reasons in more detail. Below is that detail.
We mention below calling “the emergency number“. For the U.S. and Canada this is 911, for the UK it’s 999. Ireland is 112 or 999. In New Zealand it’s 111 and In Europe and India it’s 112. In Australia it’s 000.
Back To Stopping Your Medication Immediately – Allergic Reaction
Any food, any medication, any substance, can cause an allergic reaction. This is not just a feeling that you don’t like the medication or that it gives you a headache. We mean a specific IgE-mediated allergic reaction. (IgE is immunoglobulin E.) A real allergic reaction to your medication for schizophrenia, a severe hypersensitivity reaction, can progress to “anaphylaxis”. The symptoms can come within minutes. Symptoms like hives and itching and flushed skin, wheezing and difficulty breathing, a weak, rapid pulse, nausea, dizziness, and fainting. This is life-threatening; it can kill you. You need to go to a hospital emergency department. And don’t take another dose of your medication until your doctor reviews your medical situation.
Back To Stopping Your Medication Immediately – Heart Rhythm Problems
There are a couple of heart rhythm problems of grave concern. One is called “QT interval prolongation.” The other is called “torsades de pointes.” Neither one, as you can see, is everyday conversation. But here’s the deal. You know that old expression, “What you don’t know won’t hurt you.” Well, it’s not true in these situations. Either of these heart rhythm problems can kill you whether you know about them or not.
What the heck is QT Interval Prolongation?
QT interval prolongation can make heart beats chaotic and can cause sudden heart death. So, if you’re still alive to notice the symptoms, call your doctor, stop your medication, and get help; you are better off than some people. The symptoms of possible QT interval prolongation are lightheadedness, weakness, passing out or fainting, and palpitations (palpitations means being aware of your own heartbeat), chest pain, or too fast a heartbeat. The QT interval is the time between electrical heart beats. Too long is not good. While older people and women are at a higher risk, having your QT interval change to too long can happen to anyone.
Okay, So, What the heck is torsades de pointes?
Torsades de pointes is a heart rhythm problem that is related to the prolonged QT interval problem described above. The symptoms of torsades de pointes are a fast heartbeat, lightheadedness, and feeling faint. If not treated as a medical emergency torsades de pointes can result in a sudden heart attack and death. There are mentions in the medical journals that thioridazine (Mellaril®), ziprasidone (Geodon®), and intravenous haloperidol (Haldol®) were most often associated with torsades de pointes. (“Torsades de pointes” is a French phrase for “twisting of the points”, referring to the heart beat points on an ECT [electrocardiogram, heart rhythm tracing]).
Once More on Stopping Your Medication Immediately – Thromboembolism
When a blood clot (thrombus) forms in your leg, the symptoms will be pain in your calf or thigh, leg swelling, your skin will feel warm, and on your leg you’ll see light red or purple streaks. If a piece of the clot breaks off (embolism) and gets to your lungs (this is the part that could be fatal), you’ll have shortness of breath and rapid breathing, rapid heart rate and chest pain, and might get lightheaded or faint. There’s a lot information in medical journals to say that the medications used for schizophrenia can, at times, cause leg blood clots. And, a piece of clot can break off and go to your lungs. Again, if you think you might have a thromboembolism, call your doctor. He’ll probably have you stop your medication and go right to a hospital emergency department.
Yet Again on Stopping Your Medication Immediately – Seizures
Like the adverse reactions above, it’s rare. But it can happen. You could have a seizure, also called convulsions. Almost all of the medications that are helpful for schizophrenia can increase the risk of someone having a seizure. Some of these medications increase the risk more than others. Risperidone (Risperdal®), haloperidol (Haldol®), molindone (Moban®), fluphenazine (Prolixin®), pimozide (Orap®), and trifluoperazine (Stelazine®) are less likely to cause seizures while chlorpromazine (Thorazine®) and clozapine (Clozaril®) are more likely to cause seizures. But any can cause a medically dangerous seizure, and once you have one you don’t want to have another. As before, if you have had something strange happen and you or someone else thinks it might have been a seizure, call your doctor. She’ll probably want to see you and do an EEG test (brain wave test).
More on Stopping Your Medication Immediately – Stroke
It’s also very rare, but it seems that the medications for schizophrenia can cause a stroke. The symptoms of a stroke vary. For example, a stroke might cause a sudden weakness of an arm and leg on one side of the body, or just an arm or just a leg, or part of the face. Speaking might become difficult with words hard to say or talking that make no sense. Or, the people around the person having a stroke might see that the person looks confused. Or, that they cannot understand the conversation. Vision might go bad or even sudden blindness in one eye, or both eyes. It you are the person who has had the stroke it’s unlikely that you will be the one to call the emergency medical number, but someone needs to call it. And to call the doctor for the person having the stroke.
One Last Thing on Stopping Your Medication Immediately – Pancreatitis
Once again, this is very rare, but the use of the medicines for schizophrenia can cause pancreatitis. The symptoms of pancreatitis are pain in the upper stomach area, maybe that is felt all the way through to the back, and maybe worse after eating. Symptoms might include a fever, a rapid heart rate, nausea and vomiting, and it might hurt if someone touches the stomach area. This side effect might be more likely with olanzapine (Zyprexa®), quetiapine (Seroquel®), risperidone (Risperdal®), and ziprasidone (Geodon®) than with other medications. It’s important to call your doctor but this might not be the same kind of urgent medical emergency like the conditions above. Whether or not it’s an emergency depends on how much you hurt. If the pain is really bad get to a hospital emergency department.
When Can I Get Off Treatment for Schizophrenia?
So, returning to the question, when can I get off my medication (or therapy) for schizophrenia? If you’re on a good medication that works well and that you can tolerate long term, and if you’re seeing a good therapist, don’t ever plan to stop either. Like Type 1 diabetes, schizophrenia is a lifelong condition. If you can get everything set in place for yourself, your life can be better. Stopping good medications that work well will let the next psychosis happen. And, psychosis is toxic to the brain. With each episode of psychosis your are less likely to get well when you restart a medication. And just the right therapist can be hard to find. If you’ve found her or him, stay in therapy. That’s your guide for life’s journey.
Treating Schizophrenia’s Goal to Eliminate Schizophrenia
When launching into the topic of treating schizophrenia, we have to say that the best plan would be to treat schizophrenia in a way that will just plain stop it in its tracks, before it blossoms into real trouble. To do so, we need to catch schizophrenia immediately as it starts, at that first sign of psychosis. Or even, at the first signal of an approaching psychosis. Start the right medications and therapies immediately. Then, continue to treat it with every tool we have, and never let the psychotic mental state return. It’s the goal of all medical doctors, scientists, and governments worldwide to conquer schizophrenia. And they’re getting close.
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To Be Honest, Treating Schizophrenia Can Be a Difficult Conversation
Why is treating schizophrenia a difficult discussion? Well, because, most everyone who asks questions about how to treat schizophrenia comes with a preconceived idea in mind of what answers they want to hear. And, understandably, everyone wants to hear clear, concise, easy to follow answers. So, the good news is that there can be good outcomes for someone with schizophrenia. The dilemma is that getting a good outcome is not always easy. The path forward is not a straight, clear road. It’s a winding maze to be learned and successfully navigated. Take heart, all of you who can accept a challenge. And, read on to understand.
Preventing Schizophrenia by Aggressively Treating Schizophrenia
As we said on our Schizophrenia page, there are ways to treat it that might make it possible to prevent it. But it’s a challenge. These methods require trying to learn who might develop schizophrenia. Once these at-risk people are identified, start good medications and therapies before it gets to be a full-blown bad psychosis. We now know something that we didn’t know years ago. Psychosis, the brain state in which the brain is psychotic, is itself toxic to the brain. The chemistry changes in the brain that makes a brain “psychotic” damage the brain. As a result, after a bad psychotic episode it’s easier for another psychosis to happen. And that next psychosis will be harder to treat. So over time it gets harder and harder to get the person back to normal.
Getting Back to Normal After a Psychosis – Treating Schizophrenia
Getting back to normal. That’s the plan and hope of every person who comes down with this medical condition, and the hope of everyone who loves them. To get back to life as it was before the illness hit. That’s why it’s so important to understand that the brain state of psychosis damages the brain. Because it’s true that with each episode of psychosis the person moves further and further from “their old self”. And if they get too far from their old self they can never return. The plan to prevent schizophrenia might not always work, but even if it just works partly, it works better that yesterday’s standard care.
Doing It Right – Doing It Wrong – How Hard to Hit Schizophrenia to Prevent It?
Usually people who don’t know about schizophrenia and don’t understand it believe that it should be treated gently at first, with a light touch. They might believe that it’s wrong to wallop the person with a medication hammer and a lot of therapy if all we can see is mild early signs of psychosis. This start low, go slow path has been a standard method for the past 60 years. But over the past 15 years many experts have gradually learned that exactly the opposite is true. If we could see schizophrenia sooner, earlier, when it first starts, and then hit it hard with just the right medication and therapies, we could have much less long-lasting schizophrenia.
Will Aggressive Initial Treatment Really End Schizophrenia?
Realistically, no. While it can and does work, with the best methods we have now not everyone can do it. Having said that, however, if we could actively treat as much as possible, individuals with schizophrenia would probably be much less sick. Another wrinkle in this grand plan is that too often those earliest signs are seen too late. Then, when they finally are seen, these early symptoms are too often treated briefly with a light touch. The benefit then fades pretty quickly. Another dilemma is just people. As the COVID-19 pandemic illustrated, if a person does not want to be treated, they’ll avoid it. Good advice doesn’t help, especially if someone is already suffering with psychosis.
A Reader Asks: Okay, Then, So, How Long Do I Have to Take This Medication?
This news is both good and bad. The good news is that, after trying several medications and going through all the usual fits and starts to find just the right one, you likely will find a one that works well for you. This would be a medication that you can take, it works, and you have only a few side effects. The further good news is that, once you have done this hard work and found the just-right-for-you medication, it will likely remain effective for you for a long time. The part that some people might think is bad news is that, once you find this good-fit medication, it probably should never be stopped. It’s a lifelong help, like insulin for a diabetic. Or blood pressure medicine for a person with high blood pressure. Or a cholesterol-lowering medication for someone with high cholesterol.
More Good News: There Are Many Effective Schizophrenia Medications
Today there are many medications in many forms and formulations to treat schizophrenia successfully. This wide variety gives doctors and people with the condition more choices and a better chance to find that good-fit medication. Much of the special medical skill of treating the schizophrenia involves finding that best match medication. With so many choices, one is more likely to find the right one, and might even find that right one quicker. There are newer medications, of course, and older medications. Some of the older drugs are better in some situations than the newer ones. One example is clozapine (Clozaril®). Many doctors think clozapine works the best for “positive” symptoms when nothing else has helped. (“Positive” symptoms are things like losing touch with reality, hallucinations, delusions, really odd thoughts, or acting poorly organized.)
The Medication for the Person – A Near Unique Match
Sometimes it’s easy to treat schizophrenia, sometimes not. There’s no “one-size-fits-all”, one medication that works best for everyone. To find the best medication for a person takes time and work, trial-and-error. At times it can be hard, for both the individual and for his/her doctor. While it’s true that any of the medications work better than no medication, some work better than others for a specific person. And beyond working well, considering the side effects are important to find the best fit. For a specific person likely one or only a few of the many good drugs will work well and the rest will not be good, either because they don’t work or because they have bad side effects.
At Times a Person’s Schizophrenia is Not Easy to Treat
Schizophrenia is a medical condition, a physical illness. It’s mainly a physical brain disorder though it does affect other body systems. It’s physical just as diabetes and high blood pressure are physical. Just as really bad diabetes or way too high blood pressure is harder for a doctor to treat, a really bad psychosis can make it hard for the doctor to find the right medication in the right amount. So sometimes the first medication tried works for right now but is not the best one to take for a long time.
One Person’s Side Effect can be Another Person’s Help
A good doctor can find a medicine with side effects that might actually help. For example, if you feel upset and anxious all day and can’t sleep at night, a drug with side effects of calming and sleepiness might help you feel calmer during the day and then become sleepy at bedtime. On the other hand, if you’re tired, sleepy, and feel lazy all day, a medication that gives you energy during the day might be helpful.
Calming Medications
There are medications that are well known to have calming side effects, for example, quetiapine (Seroquel®), olanzapine (Zyprexa®), or chlorpromazine. There are more medications in the list at the bottom of the page.
Energizing Medications
Other drugs give a person energy, like a cup of coffee or tea. Examples are lurasidone (Latuda®) and cariprazine (Vraylar®). Again, there are others in the list at the bottom of the page that can have this same effect.
What Works for Her Might Not Work for You
The trial-and-error testing phase is always needed because any one medication can feel remarkably different to different people. For one person, as an example, aripiprazole might give him a good sense of vigor and energy. For another person it might cause upset, anxiety, and nervousness, and he might need to stop the aripiprazole because he can’t stand this side effects.
Clozapine (Clozaril®)
There’s an almost unique “go-to” drug for schizophrenia. Only a few special doctors are permitted to prescribe it. It might set your mind right when nothing else works. It’s clozapine. The old trade name was Clozaril®. Many experts think it works better than any other drug for the “positive” symptoms of schizophrenia. Sadly, nothing is perfect. Clozapine has one rare but really bad side effect that needs to be caught early or it could kill you. So, before a doctor will give it to you he/she needs to do blood tests to look at your white blood cell count. Then, as you’re taking it, you’ll need to have more blood tests now and then to make sure you’re still okay. (If you’re one of our paid subscribers, see our specific page on Clozapine.)
But Remember there is No “One-Size-Fits-All”
For some of us, life can be hard. For most people schizophrenia is hard. And one of the hard parts is finding that best medication for you. But some people do “get lucky” and find the right medicine on the first or second try.
Those Who Work the Hardest Win the Biggest
Anyone deserves a lot of praise who can take on the challenge, spend the time, work with their doctor, and try drug after drug until the right one is found. Sometimes it’s easy, sometimes it ain’t.
List of Medications
At the bottom of this page is a long list of medications for schizophrenia that are available in the U.S.
Treating the Negative Symptoms of Schizophrenia
We briefly mentioned the “positive” symptoms of schizophrenia above. The past 70 years have been spent looking for better drugs for these “positive” symptoms, and as we’ve said above, we have many good ones. Now people are looking for better medications to help with “negative” symptoms. Negative symptoms are things aren’t there, like feeling too little emotion about life, having a poor ability to plan and follow through, poor personal hygiene, not liking social settings, always staying too quiet, or not wanting to do anything. One of the links below has a research paper on treating the negative symptoms. Here it is if you want to click it now: Treating Negative Symptoms
Medications for the Negative Symptoms of Schizophrenia
Sometimes a drug that is usually for depression helps with these negative symptoms, but not always. One that might work is reboxetine, another is mirtazapine. At first, without knowing the history, you might think that to boost social energy and mental focus a stimulant like methylphenidate or amphetamine could help. But they don’t work because they make the psychosis worse. These stimulant drugs work in the brain in a way exactly the opposite of the way the medications work that treat psychosis. So taking a stimulant would push the brain chemistry the wrong direction, push against the useful medication, and make the psychosis worse.
You Will Definitely Need More Than Just Medications
Medications don’t do it all. While a 2nd or 3rd medication might be needed to get everything in a nice place and keep it so, at some point adding one more medication is not going to be the answer. There are other valuable and necessary treatments. A big one is supportive therapy focused on social skills training. It’s really useful, in a safe therapy setting, to have the opportunity to practice talking to people, to learn and practice “small-talk”, to learn how to go about dating, and learn and try better ways of making friends. A full team of clinical helpers might be the best, coming with many abilities to help.
Cognitive (Thinking) Symptoms
Okay, so above we talked about positive symptoms and negative symptoms. We’re not done. There’s one more big category of schizophrenia symptoms: “cognitive” symptoms. Cognitive symptoms mean being poorly able to think clearly and focus your attention on something. It’s really hard to succeed in life if you can’t think clearly and quickly. With psychosis, one is less able to plan, less able to focus mentally and to concentrate, and just plain less able to think. Psychosis also makes memory worse. If your memory is poor and you forget to take your medication, it all falls apart, and the positive and negative symptoms come flooding back.
Treating the Cognitive Symptoms
When you and your doctor change you from one medication to another, it’s important to notice how clearly you’re thinking on each one. It might be best to keep a record, like a diary, of how well you (and you relatives and friends) think you’re doing on each medication, including how well you’re thinking. In some people some medications might help with thinking and some might make cognition worse. And as we mentioned above, one can’t clear thinking and mental focus with a stimulant like methylphenidate or amphetamine. They don’t work because they make the psychosis worse. In the brain the medications for psychosis push the chemistry one way and these stimulants push the chemistry in exactly the opposite way, and make the psychosis worse.
Again We Emphasize, Medication Alone Is Not Enough
As with negative symptoms, there are therapies to help push against the poor thinking of psychosis. These “cognition” therapies are really useful approaches. For example, occupational therapy helps one to practice paying attention, improving memory, setting priorities, solving hard questions, and getting the tasks of everyday life done each day. In addition, physical exercise is a great approach, so don’t overlook it. Physical exercise can help with clearer thinking. The exercise program doesn’t have to be intense physical exercise. Walking twenty minutes a day on 5 days a week is enough to make a difference in clearer thinking.
reserpine (Raudixin, Serpalan, Serpasil) – But reserpine is such a problematic medication that it probably should not be used. It has adverse effects such as severe depression, significant hypotension, exacerbation of asthma, peptic ulceration and hemorrhage, and extrapyramidal (muscle tremor and spasm) side effects.
If you think we’ve missed a good one, let us know.
Schizophrenia – A Brain in Trouble. What is real, what is not?
The Good News About Schizophrenia
There really is good news about schizophrenia and its treatment. It might be possible to eliminate schizophrenia altogether, as you’ll read in these pages. The modern medical science in this area is about stopping schizophrenia before it starts. And the medications available to treat existing schizophrenia keep getting better. New approaches with medications seek to treat the positive, the negative, and the cognitive symptoms, not just the psychosis. So take heart that it’s all good and getting better. As always, we remain on your side to praise what works, debunk anything that doesn’t work, and advocate for better medical care and better health outcomes.
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Schizophrenia is a medical condition, a brain disorder. The brain changes caused by schizophrenia change how a person shows emotions, how they think, what they believe, what they hear, and how they behave. It creates a new world that only that one person can fully experience, and it’s scary.
Getting Help for Schizophrenia Is Not a Do It Yourself Project
Schizophrenia is a serious medical condition, a clinical situation that needs the best of medical care. Below we describe symptoms of schizophrenia. It’s not a medical condition that you can identify on your own, by yourself. As with any other medical disorder, you need to see a physician, preferably a physician with good training, a lot of experience with treating it, a good heart, and a good bedside manner. The physician has to be someone who can see the signs of schizophrenia correctly, ask the needed questions, and do the right tests and scans. And then, once all the information is in, offer her opinion on whether this is schizophrenia or some other illness. Then, in discussion, design a person-specific treatment plan.
Beginning at the Beginning – Early Symptoms of Schizophrenia
Early on, that is, when a person’s illness first starts, it might just be that “something” has changed. You might not be able to put your finger on exactly what, but something’s definitely different. It’s hard to get very specific here because the first symptom can appear over a few weeks, or a few months, or a few years. It’s different for each person. It might be something quirky, like coming up with a new belief about something that seems out of character, that makes little sense. (And this change is not the healthy exploration of adolescence.) It’s different. The early signs might be comments on hearing something, but each time, no one else can hear the sound, noise, or voice. The person might seem “deep in thought” too much or too often when they’ve never been like this before.
The Common Symptoms of Schizophrenia
“Positive symptoms” are the easily seen changes of schizophrenia, the fixed false beliefs (believing something that’s clearly not true), hearing voices that no one else hears, and the scattered thinking discussed below. “Negative symptoms”, the things that are missing with schizophrenia, are described below, too. The fixed false beliefs are the delusions. The voices are the hallucinations.
Schizophrenia’s New Onset of Fixed False Beliefs (Delusions)
A person with the early signs of schizophrenia might start believing things or ideas that seem odd and unusual and that don’t make sense. Like believing that their best friend has turned against them, or that the characters on TV are talking to them. Or they might turn enthusiastically religious or might start believing that they have special powers. Special powers like, for example, that they can think their way out of trouble. And you, as a reasonable person, mighty try to explain to them that they’re being unreasonable or unrealistic, or just silly. But they don’t get it and don’t believe you. In response they get angry, or quiet, and it’s clear that they don’t believe you.
Schizophrenia and the Voices That Aren’t There (Hallucinations)
This whole area about hearing voices is a big one. The person hears someone speaking. The speaking is not some faint voice far away and it’s not a voice that they believe might or might not be there. They know it is there. To them it’s a clear voice, one that’s right here, as though someone is standing next to them talking right into their ear. Except, there’s no one there and no one else can hear the voice. And as with the beliefs, if you try to convince them that there is no voice, they won’t believe you, because they can hear the voice. They hear the voice, they know someone is speaking. It’s not just thoughts in their head, it’s absolutely real to them. A very upsetting part, sometimes the voices tell them to do things, “command hallucinations”. Seldom are the commends to do something good.
Schizophrenia’s Foggy-minded Scattered Thinking
This part of the disability of schizophrenia is supposedly new to medical science as of the past twenty-five years or so. Actually, that’s not true. Dr. Emil Kraepelin described it in the people with schizophrenia that he was treating over a century ago, but medical science “forgot” about it for about seventy-five years, focused on the psychosis. At first the person’s thinking becomes a bit scattered. And since we know how someone is thinking by how they’re speaking, their speech is scattered. We’re not talking about complete gibberish. It’s speaking in a way that’s a bit less well constructed with connected sentences. And for this person that we know, it’s out of character, not the way they usually would have spoken.
Photo by Engin Akyurt
Schizophrenia’s Symptoms on What’s Not There – The Negative Symptoms
If you know a person well these will be easy for you to recognize. The individual doesn’t have their usual spark and flash about life. For example, a person doesn’t get excited about a situation or event that usually would really be great for them. For example, if they’ve always been an avid movie buff and not they’re not interested in a great new movie release. Or, they like the person with an upcoming birthday and usually they like parties but are blasé about the party. They’d rather skip it. They just don’t want to do anything active and social. Even fun things. They might not talk about much and might be reluctant to attend social events.
One of our readers asked:
Doesn’t the schizophrenia know he’s sick? How can he not know?
Well, maybe, early on in the start of the changes the person will realize it. But, as the disorder progresses, usually at some point along the way the difference between what’s real and what’s not blurs. Then the person doesn’t know they’re sick. (See our free page on the side effect you can’t tell your doctor.) There’s another concern. What if it’s not schizophrenia? What if it’s just a reaction to a medicine for allergies, like a steroid? What if it’s a thyroid problem? What if it’s a toxic environmental exposure, like an insecticide or herbicide? An experienced physician needs to get the history, talk to the person, run the needed tests, and then make the correct diagnosis. One needs to get thyroid levels, other hormone levels, brain scans and maybe x-rays, a good medical history, and a good physical exam to understand the situation.
Symptoms of Schizophrenia In Women vs. In Men
There’s usually not much difference in the symptoms of schizophrenia between women and men. Maybe one difference is “inappropriate emotions”. This was found in a big study (1526 patients) of women and men with schizophrenia in the U.S. and India. In the study a history of “inappropriate emotions” meant that the person showed emotions that just didn’t fit the situation. And more women than men had a history of showing these inappropriate emotions, but the difference wasn’t large. Forty-two percent of the men and 55% of the women had it, so the difference was actually close to an even 50/50 split.
There Are Other Differences Between Men and Women with Schizophrenia
In this same study done in the U.S. and India there were other gender differences. The study had 395 men and 240 women in the U.S., and 480 men and 403 women in India. One difference was the course of the illness over time. Younger women (pre-menopause) had better course of the illness, meaning a less awful experience, than men. Men with schizophrenia were less likely to be married that the women. And, the women were likely to have more children than the men. Here’s a link to the study report: Women vs. Men – Symptoms of Schizophrenia Research Paper in Psychiatric Investigations.
Schizophrenia Is a Common Medical Condition
Schizophrenia is really common. Worldwide, about 77 million people have schizophrenia. It’s one of those medical conditions that equally crosses all the artificial social divisions that we human beings have constructed, affecting rich and poor, intelligent and challenged, all ethnicities, and any genders. And it’s about equal in men and women. An equal opportunity brain disorder.
Schizophrenia is a Brain-based Condition
Schizophrenia is a medical condition that affects the brain. As is discussed on our page Your Mind & Your Brain, all of the areas of our body are interconnected. So, in addition to the brain, schizophrenia affects many other organ systems like the immune system and the endocrine system (endocrine as in diabetic tendencies).
Schizophrenia is a Medical Condition
While we think this point is clear from the above discussion, we wanted to convince ourselves that we had tried to make it crystal clear: schizophrenia is physical. It’s as physical as a missing arm or leg. It is real, based in brain tissue changes. Here’s the problem. Many people use the word “mental”, as in mental illness, to mean not real. People equate “mental” with the phrase “all in your head” and use this terminology to mean imaginary. This use of the word “mental” is unfortunate and just plain wrong. Schizophrenia is not some vague, hazy thought or emotion just floating about in someone’s mind or head (or brain). It is corrupted brain hardware circuitry, hard wiring and circuits gone wrong in a person’s brain.
We Do Live in our Brain
As we’ve said, schizophrenia is a brain problem. That’s a big problem because we live in our brain. There is such a thing as mild schizophrenia, but it’s rare. (Maybe mild schizophrenia will be more common in the future.) But for now, schizophrenia is usually bad. People with schizophrenia hear voices that others don’t hear. They might view what’s going on around them in a different way. And because of the way their brain’s working they might make social mistakes and anger others. So, after a while, they start avoiding people. Why stay around people when they’re always angry? People with schizophrenia can become nervous, afraid, and upset. They might accidently upset others by making “strange” or nonsensical remarks. There are good medications that will help. It also helps to be in a secure, safe place.
We Need Better Medications for Schizophrenia
Everyone with schizophrenia and their family and friends would agree that we need better medications. Today’s best medications are huge advances over the best medications of 10 years ago. And those medications were better than the ones of 20 years ago. And those 20-years-ago medications were again incredibly better than the ones from 50 years ago. But today’s medications are still not good enough. Most people with schizophrenia never return to the way they were before the illness started. We need to fix that.
The Ongoing Explosive Revolution in Schizophrenia Knowledge and Research
We have to call the current rate of progress an explosive revolution in schizophrenia knowledge and research. For those of us in these research areas it’s really exciting. Physicians can now recognize signs in childhood that indicate the risk for eventual schizophrenia, twenty years before the psychosis starts. There are also newly found symptoms that become obvious just before the beginning of the first psychosis. We have a much better understanding of the way the disorder changes through a person’s life after that first episode. All the new information put together gives us an entirely new view of schizophrenia.
Seeing Schizophrenia Before It Begins
People have early changes in the way they behave for a period of time before the first clear signs of positive symptoms appear. People studying these changes aren’t certain how far before full psychosis the early signs can be seen. It could be that these early signs can be seen years before the obvious positive symptoms hit. As we commented above, it’s even possible that these first early signs can be seen in toddler years or infancy. Scientists are pursuing research all around the world to find out more. Many now believe that if we could tell early enough who is going to get schizophrenia we might be able to prevent it altogether.
Psychosis Is Toxic to the Brain, Making Schizophrenia Worse
The various nerve cell, nerve circuit, and chemical transmitter changes in the brain that result in psychosis are toxic to the brain. It’s like some toxic environmental exposure inside the brain. The changes damage the brain in a way that makes ongoing and worsening psychosis more likely. And, the longer the psychosis continues, the worse the toxic effect gets. The result of this situation is that if early signs of psychosis start and the psychosis is not treated quickly, it gets worse and is harder to treat. And the longer it goes untreated, the worse the condition will become and the more and more difficult it becomes to treat. In such a situation it certainly will likely never go away completely.
Image by ThePixelman
Schizophrenia Lasts a Lifetime
Schizophrenia a chronic medical condition. It lasts all through one’s life. In the old days, before we had the better medications we have now, when someone was sent to an residence hospital for schizophrenia they usually stayed in-hospital for the rest of their life. With today’s medications and other treatments the condition can improve to the point of people being almost symptom-free. A sad fact here is that too often people feel so well that they stop their medication and, as a result, their wellbeing falls apart. True, they will improve again when they restart their medication. But each episode of psychosis is toxic to the brain, so the improvement with restarting medication will likely not bring them back to the place they were before they stopped the medication.
Diagnose and Treat Schizophrenia Immediately and It Might Go Away
As we said above, in schizophrenia starting and stopping medication is an real bad idea. (See our free page on Treating Schizophrenia.) It’s likely that the psychosis makes itself worse, that is, psychosis is toxic to the brain and makes it easier for more psychosis to occur. Allowing any psychosis to persist for very long can set up the person for a lifetime of worse illness than need be. This means that if the first early symptoms start and the disorder is quickly treated and treated really well immediately, it might go away. Even if it doesn’t go away completely, the individual is likely to get better and have a milder course throughout his life.
Can We Wipe Out Schizophrenia?
So maybe if we can identify people on the path to develop schizophrenia, jump in with aggressive treatment as soon as the first signs appear, and keep the treatment going, we could wipe out schizophrenia altogether. Eliminating schizophrenia is a goal of everyone close to the condition: physicians, scientists, patients, family members, and friends. And we’re getting close. See our free page on Treating Schizophrenia.
Schizophrenia’s Causes are Complicated and Varied
There are a couple of life situations that greatly increase the risk for schizophrenia. One of these situations is everything a person goes through from the start of pregnancy to today, for example, events during fetal life while Mom is pregnant. The other situation is your ancestors, specifically the genes you inherit. What genetics did you inherit from mom and dad, grandparents, and other ancestors? As all the parts of life’s experiences and genes mix together, you can understand that schizophrenia in one person might be different from schizophrenia in another individual. This means that there is not just one disorder, “schizophrenia”, but many, many similar disorders, the “schizophrenias”, each a bit different. And, while these different schizophrenias might look similar, they are not. Yes, it does get confusing.
The Baby in the Womb and Schizophrenia
We have no control over what happens to us while our mothers are pregnant with us. Many situations that affect the developing baby can occur. Damage to a developing baby is one possible cause of schizophrenia even though the disorder does not appear until teenage years or in young adults. These problem influences on a baby’s well-being include a mother’s temporary diabetes while she is pregnant, any bleeding that she has during pregnancy, and events that can go wrong in labor and delivery like too little oxygen, an emergency C-section, and low birth weight. Another possible problem is infections that a mother has during the middle part of her pregnancy. Or a mother’s high stress levels during this time. These situations might lead to additional problems for the baby. These effects during the middle 3 months on the forming baby could double the risk of developing schizophrenia.
Schizophrenia Does Indeed At Times Run in Families
Schizophrenia can and sometimes does run in families. Families with one family member with schizophrenia are more likely to have other family members with it. Or, consider adopted children born to biological parents with a genetic risk for schizophrenia. They seem to have the same risk for getting schizophrenia in their new, adoptive home as they would have had if they had stayed in the home of their biological parents. So here it’s the genes, not the childhood environment. Schizophrenia also runs in families that have family members with bipolar disorder (manic depression). So, these two conditions are genetically linked in some way.
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