Pharmacotherpy

Medications are an important part of a client's treatment; it treats the symptoms of psychosis and helps to prevent any further episodes of psychosis from occurring. These medications are called anti-psychotic medications or neuropeltics; which can be further divided into typical (also referred to as conventional) or atypical (also called newer) anti-psycotics (CAMH, 2009). Some of the newer (or atypical) antipsychotics include Aripipazole, Clozapine, or Risperidone, while the conventional (or typical) antipsychotics include Chlorpromazine, Fluphenazine, Haliperidol and Perphenazi ne. It may take up to weeks to start seeing the effects of these medications.

Trying different medications and dosages may lengthen this process, as the goal is to control the symptoms with the lowest dosage possible. The antipsychotic medications may also be combined with antidepressants or anti-anxiety medications if needed. The medication that is used depends the person’s willingness to adhere to medications, for example someone who is unwilling may be given medication injections compared to someone who is willing would be given pills. If the person appears to be agitated, they may be given a benzodiazapine combined with an antipsychotic (Mayo Clinic, 2010). If the client is not responding to any of the regular anti-psychotic medications Clozapine may be used as clients have been shown to respond well to it when they do not respond well to the other medications. Clozapine is not used as a first resort because it can be related special risks with use, such as harm to white blood cells. Clients need to continue taking their prescribed medications even after their symptoms have been relieved because once they stop taking their medications, it is likely that their symptoms will reappear (CAMH, 2009).

Medications ideally would be prescribed in the prodomal phase of psychosis but it is also possible to prescribe the anti-psychotic medications in the acute phase as well. The prodomal phase is ideal as this phase is aimed at treating the symptoms that are present and reducing the severity of these symptoms. Patients should continue to take their medications in the recovery phase to attempt to prevent relapse and increase the overall functioning of the patient (GuÌaSalud, 2010b).

=**__Side Effects of Anti-Psychotic Medications__** =

Treatment will typically begin with a low dose of an anti-psychotic medication as to monitor the side effects of the medication on the client. If side effects are going to appear (some clients may not experience any side effects of the anti-psychotics) they will frequently be observed within hours to weeks of starting the medications. Additional medications may be prescribed to combat these side effects. Some of these side effects can include drowsiness, weight gain, blurry vision, dry mouth, restlessness, stiffness, muscle spasms or constipation just to name a few. The side effects may also vary depending on if they are typical or atypical medications. For example atypical medications are more likely to cause weight gain. It is also possible that these side effects are present at the beginnig of pharmcological treatment and that they may disappear as treatment continues (CAMH, 2009).

Those who are on anti-psychotic medications for long periods of time are at risk of developing Tardive Dyskinesia (TD), which are involuntary movements of the mouth, tongue, jaw or fingers. For each year spent on anti-psychotic medications there is a 5% increase of developing Tardive Dyskinesia (CAMH, 2009). Those who are suffering from TD are more likely to have significant side effects related to cardviovascular and hematological (blood) systems, the central nervous system, they may show symptoms similar to Parkison's Disease or Dyskenisia (such as disturbed gait, or abnormal tongue and facial movements) and behavioural issues. The central nervous system side effects can include impairments in memory and learn, disturbed sleep patterns and depressed affect. The behavioural issues can include motor restless and self injury. These side effects can vary based on many different factors of the prescription (such as dosage, frequency or discontinuation). If there is a change in medication and the person is suffering from TD, they can suffer from the side effects listed above as well as related to the gastrointestinal (change in stool and appetite for example), endocrine and genitourinary systems (urine retention and involuntary release), ears, eyes, nose, throat, skin, allergies, and temperature (Maston, Rivet, & Fodstad, 2010).

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=**__How do Anti-Psychotic Medications Work?__** =

These medications affect dopamine because when the medications were first appeared, patients showed similar symptoms to Parkinson's Disease (which is related to a lack of dopamine transmission). There are five different dopamine receptors; the most commonly affected by anti-psychotic medications are the group of D2 receptors (which consists of D2, D3, and D4 receptors). This group of D2 receptors all have similar sensitivities and structure to the medications, while D1 receptors (D1 and D5) have similar sensitivities and structure to each other. For a dose of the medication to be effective, it needs to block approximately 60 to 80% of the D2 receptors. Currently, there is question about the clinical relevancy of the D1 type receptors in the effectiveness of the anti-psychotic medications. The newer antipsychotic medications have also been found to block the serotonin receptors as well (Seeman, 2002).

Some current research suggests that a key characteristic of anti-psychotic medications is the prefrontal cortex function but the mechanism(s) of how this occurs are not completely understood. One possible mechanism is that the hyperactivity of the prefrontal cortex is inhibited by the blocking of the serotonin receptors in the prefrontal cortex. This may possibly be linked to the increased transmission of dopamine in the prefrontal cortex. It is also possible that blocking the dopamine receptors may counteract the increased prefrontal cortex activity (Artigas, 2010). More research on the mechanisms is currently needed to fully understand the effects of the medications and the mechanisms of psychosis.

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=__**Patients' and Health Care Providers' Views on Anti-Psychotic Medications** __=

The overall effectiveness and the drugs availability to prevent relapse of conventional (or typical) anti-psychotic is satisfactory to patients and health care providers. Approximately 60% of patients in one study showed satisfaction with conventional anti-psychotics. Even though the overall satisfaction is high, patients who are on the conventional anti-psychotic medications have negative attitudes towards the drug with regards on improvements in their quality of life; more specifically employment and recreational abilities. To many of the patients, gaining employment is seen as an important part of recovery (Tsang, Fong, Fung & Chung, 2010).

There is discrepancy between health care providers as to which category of medications work best. Approximately 40% of psychiatrists in a study agreed that atypical (or newer) anti-psychotic medications are superior to the typical drugs; while approximately 35% were undecided (Tsang, Fong, Fung, & Chung, 2010). While Matson, Rivet and Fodstad (2010) found there are no significant differences between the two categories of anti-psychotic medications in effectiveness or number of side effects. A high number of psychiatrists (75%) agree that the atypical medications have less side effects compared to the typical medications. The authors of this study theorized that the lack of awareness of the effectiveness of the atypical medications is due to lack of education and promotion. Patients should always be given information (such as effectiveness and side effects) of the prescriptions that they are being given and alternatives to the medications (Tsang, Fong, Fung & Chung, 2010).

**//Case Example//**
Based on the information presented above, Tom would most likely be put on an atypical anti-psychotic medication once he presented at the hospital to deal with his preoccupations with the aliens. The atypical anti-psychotic would most likely be used because of better tolerance and less side effects; a coventional anti-psychotic medication will typically be used as a second line of treatment, should the atypical medications not work effectively. The most commonly used would be Olanazpine, Risperidone, Aripiprazole, Quietiapine or Amisulpride. As a last resort to control the symptoms, Clozapine will be prescribed. It will be a process of trial and error to find the correct medication and dosage for Tom. If necessary, a benzodiapenzine or anti-depressant medication would be prescribed to Tom. He would need to continue taking these medications once the right prescription was found to prevent relapse and the appearance of the positive and negative symptoms. It would most likely be recommended that he also seek some forms of therapy as well (GuÌaSalud, 2010a).