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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.
The thing is, the approach to treating schizophrenia has not changed much in the past 75 years.
The Start of a Revolution in Treating Schizophrenia
A Bit of Pharmacology History
In 1950, a big breakthrough changed how schizophrenia was treated. Chlorpromazine (Thorazine), a medicine that helped ease symptoms of psychosis, was discovered by accident. Before this, treatments were often harsh and ineffective, like insulin coma, lobotomy, heavy sedation, or early, crude forms of electroconvulsive therapy (ECT). (Modern ECT is much gentler and safer and even suitable for pregnant women and the elderly.)
Chlorpromazine paved the way for a flood of new medications: haloperidol (Haldol) in 1958, then others like trifluoperazine (Stelazine), thioridazine (Mellaril), fluphenazine (Prolixin), and clozapine (Clozaril). By the 1990s, newer medications like risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel) came into use. These drugs often improved patients’ lives, though they came with side effects, sometimes really awful side effects.
Today’s Medicine Today – No Great Shakes
Today, the standard approach to treating schizophrenia starts with a detailed evaluation. Doctors gather information about symptoms, trauma history, substance use, and medical history. They assess the patient’s mental and cognitive state, as well as risks for suicide or aggression. If psychosis is confirmed, an antipsychotic medication is almost always prescribed.
Wake Up, Medical World – Speed Is Important
But here’s the problem: this process is often slow. Weeks, months, or even years can pass as doctors try one medication after another, with patients remaining in a psychotic state as one after another medication is tried. The mindset is often, “We are trying.”
However, these past several years medical science has realized something alarming. Psychosis is toxic to the brain. It’s like brain poison. The longer someone stays psychotic, the harder it becomes for their brain to recover. This discovery has shifted the way we think about treating schizophrenia.
Oh, By the Way, Welcome
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Part II. New Information & A New Treatment Plan for Schizophrenia
With Realizing that Psychosis is Toxic to the Brain, a Revolution in Schizophrenia Treatment Starts
Why Treatment Needs to Start Fast
Since psychosis damages the brain, it’s critical to treat it immediately. At the first signs of trouble, effective medication treatment must begin. Waiting for a confirmed diagnosis could cause irreparable harm to the person’s brain. It’s similar to the situation in medicine when an antibiotic for an infection is started before the exact bacteria is identified. Acting quickly prevents the illness from getting worse. It’s important to start even if details need to be worked out later.
Start Your Engines and Hit the Accelerator
This rapid-response approach works for people of all ages, from children to the elderly. Early treatment improves the chances of a full recovery from psychosis and reduces the likelihood of future psychotic episodes, hospitalizations, and life disruptions. It’s the difference between someone being able to date, finish school, and hold a job versus struggling with a major lifelong disability.
Polish That Crystal Ball and Predict the Future
Predictions are hard to make, especially about the future. (Some attribute this wisdom to the famous baseball player Yogi Berra, others say it came from the pen of renowned author Mark Twain.) But what if, instead of waiting for that first psychosis to appear, we could predict who is likely to experience psychosis even before it happens? That’s where biomarkers, medical clues like family history, brain health markers, and genetic background, come into play. These markers are helping doctors identify people at high risk for psychosis so that they can intervene early.
Healthy People with Healthy Brains Taking Antipsychotics
But that’s where this grand plan hits a dilemma. Not everyone at high risk ends up having psychosis. Studying these individuals may help us understand why some people develop the condition while others don’t, even with similar risk factors.
A Reader from Wyoming Asks: Does this actually work, or is it all just theory?
This reader, who said they lived in Wyoming, wrote to say that that whole mental illness schizophrenia area seems medically ill-defined. Maybe it’s all nonsense. So, it feels like speculation on nonsense to propose that an illness we’re not even sure exists in the first place can be eliminated by drugs.
We appreciate all feedback from each of our readers, and thank the reader for writing. That said, we clearly would take issue with this reader. We view psychosis as a well-established brain disorder, and further, a disorder that is toxic to the health of the brain. But our reader might have a valid point that is not immediately obvious.
Using the term “schizophrenia” has been criticized by learned and astute physicians and medical researchers. (See below the reference to the paper, “Eliminate schizophrenia”.) Even in medicine, even in psychiatry, the label “schizophrenia” is used to refer to many, many medical conditions. And the symptom of psychosis is seen in people who don’t have “schizophrenia”. They argue that the word is just a label and not a useful diagnostic term. It’s not a disease one can nail down with any certainty. These experts feel that medical science and practice should refer to the basket of problems that land under the schizophrenia label with a broad, ill-defined basket label, like “psychosis spectrum illnesses” until the science can tease out what is what with some better level of certainty.
Part III. The New Plan Hits Rough Water
At First It Seemed Like Such a Great Idea.
But, Treating People Who Are Well, Who Might Never Get Sick?
New discoveries often come with challenges. How’s this for a challenge. About half of the young people identified as high-risk for psychosis never develop it. That’s quite a hurdle to jump for this idea of treating the first episode of psychosis before it starts. Some high-risk-for-psychosis Individuals have been followed for over ten years to see if they ever become psychotic. Nope, they did not, or at least about half of them did not. But, many of that half who never become psychotic did fall ill with other psychiatric conditions, such as depression and anxiety.
Antipsychotics for Healthy People
You see the dilemma that this whole situation creates. The logical reasoning of this path is that we should give antipsychotic medications to people at high risk BEFORE they become psychotic. But, half of them will never become psychotic. Should we give these potentially harmful medicines for psychosis to healthy people who might never become sick? No, probably not. The drugs used to treat psychosis do have side effects. Some of them are really problematic side effects. Like weight gain, diabetes, and heart problems. Plus, just the act of telling a healthy person that they’re at high risk for some day becoming psychotic would upset about anybody. Such “news” could ruin a person’s whole outlook on life.
It’s One Thing If They’re Already Psychotic…
So, let’s back up for a moment. This is an easier decision if psychosis is already present. It’s clear that an existing and present psychosis, even the first hints of a real psychotic episode, need to be treated immediately. This immediacy is backed by strong medical evidence. But there’s little evidence for preventing a psychosis with antipsychotics just because an individual is identified as a high-risk. When there isn’t any hint of psychosis and they’ve never had a psychotic episode, why do anything? Though some experts advocate for pursuing less risky interventions in these identified-high-risk people, like psychotherapy or social support. It might be that these therapies are just as effective at preventing psychosis without the side effects.
Then There Is That Risk of Depression and Anxiety
Here’s another perspective. As we said above, among the group of high-risk individuals who never develop psychosis, over half have other psychiatric disorders, mostly depression and anxiety. Though antipsychotics were designed to treat psychosis, they can often work really well to treat anxiety or depression. This raises the possibility that early treatment might prevent other psychiatric disorders, not just psychosis.
Oh, The Ethics of It All
Coming at this dilemma from an ethical perspective provides new questions but really no new answers. Treating someone who isn’t psychotic but is at high risk is tricky. It might be defensible to treat someone without their consent when they are psychotic. Someone in the middle of a psychotic episode might not even know who they are, or where they are, or what’s happening around them. It’s hard to say whether a truly psychotic individual can even give authentic informed consent for accepting to take a medication. Or, refusing it. It’s like saving the life of someone unconscious after a car crash. One just saves the life absent any consent or refusal. We save their life. But on the other hand, unlike a psychotic person who might not be capable of informed consent or refusal, individuals who are not yet psychotic can decide for themselves. They are able to weigh the potential benefits against the risks and make their own informed choice.
Part IV. Well, Good Grief, Now What Do We Do?
We’re in a Quandary: And, Current Studies are Giving Mixed Results.
Is There a Middle Ground Approach?
So, what’s the best way forward? Imagine someone at high risk of psychosis due to their family history, their genetic makeup, and their adverse life experiences. Their doctors present them with a set of options. Maybe watchful waiting with regular mental status monitoring. Or perhaps starting a therapy (like Cognitive Behavioral Therapy). Would they like to involve family members in this decision. Finally, would they like to start a medicine for preventing psychosis.
Could The Safest Option Be Opting for the Medicine?
Some argue that if someone is at extremely high risk, starting medication might be the safest option. For example, a woman at high risk might take an antipsychotic and avoid a future psychotic episode altogether, allowing her to live a normal life. Assuming any side effects are mild, this could be a great option.
Tailor-Made, Bespoke, for Clothes That Fit
Bottom line, there’s no one-size-fits-all solution. One cannot grab a dress or shirt off the rack and have it always be just right. It’s a medical debate that balances the promise provided by early intervention and a better outcome against the risk of over-treatment. Ultimately, individuals must be fully informed and then empowered to make their own decision, maybe starting with less invasive approaches like therapy.
When Is The Medication Route Absolutely Necessary?
We are left with the one clear mandate. if someone is already experiencing psychosis, immediate and aggressive treatment with medications is essential. Antipsychotics, combined with education, therapy, and social support, are the best way to protect the brain from the toxic effects of psychosis. Without medication, the other interventions are unlikely to succeed.
The Ultimate Goal is Health
The goal remains the same: to reduce the impact of schizophrenia on someone’s life and help them to live fuller, healthier lives. While the road is still uncertain, the commitment to finding better solutions continues.
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.
When I sit across from someone hearing the word “schizophrenia” for the first time, I’m not thinking about receptors and scan results. I’m thinking about a life that just swerved off the road, and about how we can coax it back, inch by inch, without losing the person along the way.
Schizophrenia is a medical illness of the brain, as real and physical as diabetes or high blood pressure, but it attacks the parts of us we recognize as “who we are.” Treating it is not about turning someone into a “zombie”; it’s about protecting their thinking, their relationships, their future. My job is to be brutally honest about the difficulty of that work and equally honest about the hope that still exists, even when the path has been long and full of detours.
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Why We Treat Early and Hard
As we said on our Schizophrenia page, we now know something crucial that earlier generations of psychiatrists did not fully appreciate: psychosis itself is toxic to the brain. Every untreated or under‑treated episode leaves a kind of chemical and structural “bruise,” making future episodes easier to trigger and harder to treat.
That’s why early intervention in psychosis programs exist, and why we push to recognize and treat the very first signs quickly and aggressively. When we shorten the time between the beginning of psychotic symptoms and effective treatment, people tend to have better long‑term functioning, fewer relapses, and more chance to stay in school, work, and relationships.
This is the core of the long‑term hope: if we can consistently catch psychosis early, treat it intensively, and support people for the first several years, we may dramatically reduce how many individuals go on to develop chronic, disabling schizophrenia. We are not there yet, but the trend of research is pointing in that direction.
Medications: Finding the Right Fit
Most people with schizophrenia will need medication, often for the long haul, the way a person with severe diabetes needs insulin. That’s a hard truth, and it’s okay if you don’t like hearing it. But the other side of that truth is that we now have a very large toolbox.
There are older “typical” antipsychotics and many newer “atypical” ones, each with its own profile of benefits and side effects: some are more calming, some more energizing, some fairly neutral. We use that to our advantage. If you are pacing all night and can’t sleep, a more sedating medication might be a blessing; if you are flat, withdrawn, and exhausted, a more activating one might help you engage again.
Sometimes we hit on the right drug early; sometimes we don’t. What I ask of patients and families is stamina: the willingness to keep working with me through trial and error, because once we find a medication that keeps psychosis quiet and is tolerable, staying on it can protect the brain and your life plans over years, not weeks.
When Standard Treatment Isn’t Enough
Roughly a third of people with schizophrenia do not respond well to the first couple of standard medications; we call this treatment‑resistant schizophrenia. That phrase sounds like a verdict. It isn’t. It’s a flag that we need to change our strategy.
Clozapine remains the most effective medication we have for many people whose symptoms have not improved with other drugs. It can reduce hallucinations and delusions, help with suicide risk, and sometimes bring someone back when nothing else has worked, but it requires regular blood monitoring because of rare but serious side effects. For the right patient, though, it can feel like finally getting traction after years of spinning the wheels. See our specific page on Clozapine.)
Even beyond clozapine, there are augmentation approaches under study and in use: adding medications that modulate glutamate or serotonin systems, targeted psychotherapy, neuromodulation strategies, and careful, evidence‑based combinations of antipsychotics. These are not miracle cures, but they are reasons not to give up when the first lines have failed.
What’s New Now: A Turning Point
For decades, almost all antipsychotics worked the same way. They blocked dopamine receptors. That’s changing. Recently, the FDA approved a medication called xanomeline-trospium (Cobenfy), which targets cholinergic receptors instead of the usual dopamine pathway. It offers a new mechanism for controlling symptoms, and researchers are working to understand which patients benefit most and how best to fold it into real‑world treatment.
Other novel drugs are in late‑stage development or early approval: agents like milsaperidone (Bysanti), newer serotonin-dopamine modulators, and medications such as brilaroxazine and LB‑102 that aim to improve not just positive symptoms (hallucinations, delusions) but also negative and cognitive symptoms. Several muscarinic modulators and M4‑focused compounds are being studied as well, hoping to calm psychosis with fewer movement or metabolic side effects.
For families who have watched someone they love struggle through multiple medications, hospitalizations, and side effects, this pipeline is not abstract; it is the possibility that the next drug we try will work differently enough to finally help where others have failed.
Looking Ahead: Can We Prevent Schizophrenia?
A question I hear, usually whispered, is: “Doctor, if we’d caught this earlier, could we have stopped it?” The honest answer is that in some people, early, intensive treatment of psychosis can prevent a first episode from becoming a long‑term, disabling illness, and in many others it can soften the trajectory and preserve more functioning.
Early psychosis programs that combine medication, psychotherapy, family education, school or work support, and skills training have shown better quality of life and symptom control than usual care. The more consistently we can deliver that kind of care from the very beginning, the closer we get to transforming schizophrenia from a life‑dominating disease into a serious but manageable condition. And even, for some, to preventing chronic schizophrenia from ever fully taking hold.
Will we completely eliminate schizophrenia? Not in the immediate future. But each step, such as screening young people earlier, shortening the time from first symptoms to treatment, expanding access to effective therapies, and developing medications that protect thinking and motivation, moves us away from inevitability and toward prevention.
More Than Medicine: Rebuilding Daily Life
Medications quiet psychosis, but they do not rebuild a life on their own. Many people with schizophrenia struggle with “negative” symptoms (such as a lack of motivation, emotional flatness, social withdrawal) and “cognitive” symptoms (like trouble focusing, organizing, remembering). These are often what keep someone from finishing school, holding a job, or maintaining relationships, even when the voices have faded.
Here, structured therapies matter: social skills training, cognitive remediation, supported employment and education, and family interventions that teach everyone how to navigate stress and relapse warning signs. Occupational therapy and day programs can help rebuild routines and confidence. Even simple, steady physical exercise, for example, walking most days of the week, has evidence for improving mood, cognition, and overall functioning.
If you are a patient, a parent, a partner, or a friend, you are not supposed to figure all of this out alone. A good treatment plan puts together medications, therapy, skills training, and community support into something that feels like a path, not a maze.
A Word of Hope at the End of a Hard Road
If you are reading this after years of trying medications, after emergency rooms and locked units and nights you thought would never end, talk of “hope” can sound hollow. I understand that. The hope I’m talking about is not a promise that if you just “try harder” everything will be fine.
It is the quieter, sturdier hope that comes from seeing new treatments arrive after decades of stagnation, from watching patients who were once stuck in revolving‑door hospitalizations finally get several stable years, from early‑intervention teens who finish college instead of disappearing from their own lives. It’s the hope that even if your schizophrenia has been “treatment‑resistant,” it is not resistant to every new idea, every new medication, every new support we can bring.
My commitment, and the commitment I hope you feel from any doctor you work with, is simple: we will keep walking with you, adjusting, learning, and using every tool, every current tool and every merging discovery, to protect your mind and your future as best we can.
List of Medications
At the bottom of this page is a long list of medications for schizophrenia.
haloperidol (Haldol) – oral and injectable – activating, energizing x
thiothixene (Navane) – calming, sedating x
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.
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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When I sit across from someone hearing the word “schizophrenia” for the first time, I’m not thinking about receptors and scan results. I’m thinking about a life that just swerved off the road, and about how we can coax it back, inch by inch, without losing the person along the way.
For families who have watched someone they love struggle through multiple medications, hospitalizations, and side effects, this pipeline is not abstract; it is the possibility that the next drug we try will work differently enough to finally help where others have failed.
Here, structured therapies matter: social skills training, cognitive remediation, supported employment and education, and family interventions that teach everyone how to navigate stress and relapse warning signs. Occupational therapy and day programs can help rebuild routines and confidence. Even simple, steady physical exercise, for example, walking most days of the week, has evidence for improving mood, cognition, and overall functioning.
