Antipsychotics

Psychosis changes your way of perceiving yourself, other people and the world. Having a psychotic episode distorts your perception of the world.

You can be preoccupied with whether something is about to happen that someone has set in motion. And you may feel you are being drawn into a staging of events. This can lead to confusion and powerlessness, but it can also lead to suddenly realising a truth about how everything fits together. Some people find it terrifying. Others may find it has a calming effect, because you have the feeling of having understood how things really work. Conflict may arise when it emerges that other people are of a different opinion.

During psychosis, hallucinations of sight, hearing, smell, taste and touch often occur. You might hear someone talking about you even though there are no other people present. Perhaps you see shadows or more lifelike things that no one else can see. You might have a perception that your food tastes different, that drinking water smells strange, and that something is touching you, even if there is nothing near you.

People often have strange bodily sensations, like pressure from within, or that your thoughts are being pushed from side to side. People who experience these hallucinations for an extended period will often develop explanations for the hallucinations to the effect that someone is trying to get at you from the outside. This can make you feel you are being persecuted, or you may experience other types of delusions.

Anyone can have a psychotic episode. If you have experienced a high fever in which you talk deliriously or see things that are not there, you have experienced psychosis. These psychotic states are often transitory and pass of their own accord as the fever recedes. Psychotic states triggered by physical illness are treated somatically, i.e. at non-psychiatric hospitals. Psychiatric services treat schizophrenia, paranoid psychosis, schizoaffective psychosis and acute and transitory psychotic states.

Schizophrenia

Distortion of thoughts and of perception of reality. You may experience hallucinations, delusions and your thoughts being affected.

Paranoid psychosis

Psychic disorder primarily characterised by delusions, but not hallucinations.

Schizoaffective psychosis

Occurs combined with mania or depression.

Psychosis induced by drug abuse

Abuse of marijuana or other substances can induce psychosis.

During psychosis, many people have the perception that their thoughts are being influenced or manipulated. You may find sound entering into your thoughts, that your thoughts are being transmitted to other people, or that other people’s thoughts are being transmitted to you, so that you have one or more extra sets of thoughts to keep track of. You may also feel that your thoughts are being removed (theft of thoughts), that your thoughts have stopped (cessation of thoughts) or that your thoughts are repeating (echo thoughts).

These perceptions can mean that you withdraw from other people and try to protect yourself with sunglasses or a cap pulled down over your ears. You devote a lot of resources to paying attention to your inner thought universe.

Some may perceive that they are being controlled by another power. They feel quite distinctly that someone or something is thinking their thoughts, feeling their emotions, speaking with their voice or moving their body, e.g. by writing with their hand.

Before a psychotic episode, the person often feels turmoil and irritation – a feeling of foreboding. You may perceive that light is changing in intensity, and that sounds become sharper or weaker. You may feel alienated from your own body and thoughts. You may perceive changes in the appearance of your surroundings, and that some sensory impressions become stronger, while others become weaker. You may have difficulty sleeping and have a feeling of dreams floating into reality. It can be more difficult to cope with everyday tasks, and you might withdraw socially. Either because you are preoccupied with your inner universe, or because you are afraid to be around other people.

Family members and other loved ones will often find psychosis quite terrifying. They no longer know the person because his/her manner has changed and is now characterised by mood swings, strange utterances and different habits and routines. Perhaps their relative’s personal hygiene leaves something to be desired, and there is less contact. In other situations, the person having a psychotic episode may seek out his/her relatives very frequently. The person may appear hostile or may become angry if his/her perception of reality is questioned.

Relatives are advised not to question the person’s perceptions. Do not try to correct their perception of reality; instead, listen with empathy.

During a psychotic episode, the person has an imbalance of the neurotransmitter in the brain known as dopamine. Some areas have too much dopamine and other areas have too little. When there is too much dopamine in the areas of the brain that deal with thinking, sensing and collecting our consciousness, the familiar symptoms of psychosis occur. You have different types of hallucinations, with a distorted perception and interpretation of reality. Antipsychotics work primarily by stabilising the dopamine in the brain.

As you feel the medication taking effect, your thoughts become clearer and you have fewer hallucinations. For example, you may find the voices become weaker, or that they disappear altogether. You may also find that the impressions you believed were 100% true may now be challenged and modified. If, for example, you were previously fully convinced that your neighbour had evil intentions, you will now have more doubts and be more flexible in your thinking. You will be able to find other explanations for what you previously were convinced could not be anything else.

• Olanzapine
• Quetiapine
• Clozapine
• Zuclopenthixol

In addition to their antipsychotic effect, these types of drugs are also effective for treating anxiety and sleeping difficulties. The most frequent side-effects of this type of medication are increased appetite, dizziness, tiredness and changes in the way the body metabolises sugars and fats.

• Clozapine

Clozapine is a special type of antipsychotic drug. It has a stronger antipsychotic effect than any other antipsychotic drug. However, it is never the first choice for treatment because of rare, but serious side-effects affecting bone marrow and cardiac muscle.

• Haloperidol
• Risperidone
• Paliperidone
• Amisulpride
• Perphenazine
• Ziprasidone
• Lurasidone

These types of medication have an antipsychotic effect and generally do not increase appetite or cause drowsiness. The most frequent side-effects of this type of medication are muscle stiffness, involuntary movements and trembling. If unpleasant side-effects occur in muscles and joints, Orphenadrine can be used. Orphenadrine helps to mitigate unpleasant mobility effects. There are also sexual side-effects, with disruption to menstruation and swollen breasts in women, and erectile difficulties in men.

• Aripiprazole
• Brexiprazole
• Cariprazine

In addition to its antipsychotic effect, Aripiprazole drug also has the effect of stabilising moods. The most frequent side-effect of Aripiprazole is a feeling of inner turmoil and restlessness, although most people only experience this at the start of treatment. Brexiprazole and Cariprazine has the same effects as Aripiprazole.

All drugs are available as tablets, and many can also be obtained as orodispersible tablets that dissolve quickly in the mouth. Some tablets (Ziprasidone and Lurasidone) have to be taken with food in order to be correctly absorbed by the body. Many drugs (Olanzapine, Ziprasidone and Aripiprazole) are available as an emergency injection.

Several drugs (Haloperidol, Perphenazine, Risperidone, Olanzapine, Paliperidone, Aripiprazole) are available as slow-release medications, i.e. an injection with a long-lasting effect administered fortnightly or monthly.

Your therapist’s first choice will be to use drugs that are known to have the fewest side-effects. It varies from person to person which drug is most effective and at the same time has the fewest side-effects. That is why it is impossible to predict which medication will work best for you. It may often be necessary to switch from one type of medication to another in order to achieve the best possible effect and as few side-effects as possible.

As a general rule, you will be treated using one type of antipsychotic medication at a time. An exception could be that, at times, you need extra medication in addition to your basic treatment. Here, by agreement with your therapist, you can get a prescription for a small dose of an antipsychotic drug (to take as and when needed), which you can take 2–4 times a day if needed.

Antipsychotics – just like any other type of medicine – may have different side-effects. Not everyone gets side-effects from treatment. When people do get side-effects, the degree varies and it often depends on how large a dose you are given. For some people, therefore, it can be beneficial to reduce the dose instead of switching to a different drug.

When you start taking the medicine, several months may go by before the full antipsychotic effect is achieved. Possible side-effects may be evident as soon as you start taking the medicine, but they often diminish over time.

Usual side-effects

• Trembling or muscle stiffness
• Inner turmoil and restlessness
• Increased appetite and weight gain
• Effect on blood cholesterol
• Effect on the white blood cells in the blood
• Effect on cardiac rhythm
• Increased saliva production, or dry mouth
• Sexual irregularities, such as reduced libido and difficulties getting an erection and/or climaxing
• Hormonal disturbances, e.g. changes in the menstrual cycle
• Allergic reactions

When you are prescribed antipsychotics, it is always a doctor in charge of your treatment who issues repeat prescriptions and ensures that the guidelines for your treatment are being adhered to. The doctor will ask questions about the effect and side-effects of the medication, refer for and interpret blood tests, measure changes in weight and waistline and refer for and interpret electro-cardiograms (ECG). If you are being treated with several different kinds of medication at the same time, your doctor will monitor for any interactions of the drugs.

The treatment of psychosis is divided into different phases. An acute state is treated as described under “the acute phase” and “the stabilisation phase”, while a more persistent state is treated as described under “the stabilisation phase” and “the maintenance phase”.

The acute phase:

The acute phase is characterised by a number of symptoms of psychosis such as auditory hallucinations, paranoia and your thoughts being affected. You function less well in your daily activities, you are less able to take care of yourself, and have difficulty taking care of ordinary, everyday tasks. You could also be anxious and restless, or find it difficult to be at peace. The treatment is directed towards the acute symptoms of psychosis, and you will often be offered a drug that causes drowsiness. However, during the acute phase, there have been positive experiences of using antipsychotics that do not primarily cause drowsiness, but which act rapidly and effectively. A fast-acting injection or inhalation are examples of these.

The stabilisation phase:

During the stabilisation phase, you still have symptoms of psychosis, but you are more at peace, and the treatment is beginning to work. You are able to drink, eat and sleep and you are better at communicating with those around you. This is often the phase when you will be discharged for follow-up with the regional psychiatric service, a GP and/or the municipality. The stabilisation phase is a vulnerable phase, when cohesive treatment really matters. Medication will be given on the basis of a forward-looking perspective, and often you will be switched to a drug that causes less drowsiness and an adjustment of the dose, depending on the effect and side-effects. During this phase, many people are offered slow-release medicine, i.e. antipsychotics administered as a fortnightly or monthly injection.

The maintenance phase:

During the maintenance phase, you get to know your disorder and become more adept at looking after yourself. You will often be in outpatient treatment, talking to your therapist about the early warning signs of psychosis in order to avoid a relapse. Some will still have symptoms of psychosis that they learn to live with. You will be taught about your disorder and symptoms of psychosis. Your medication will be constantly monitored, and your treatment will be reduced to the smallest possible effective dose. You might need to switch to a different drug, e.g. because of side-effects.

• Is this your first psychotic episode? 1–2 years of treatment
• Have you had a psychotic episode before? 2–5 years of treatment
• Have you had more than one psychotic episode before? At least 5 years of treatment

If you are admitted to hospital, your medication will be administered and issued by the ward staff. Well before you are discharged, a plan will be prepared for your medication going forward, and any relevant medication grants will be applied for, such as one-off subsidies or chronic grants. If you have had medication as an injection (slow-release medication) while in hospital, a plan will be prepared for how you can get your medication after discharge. This could, for example, be in the context of the outpatient psychiatric treatment provision, from your GP or a health centre in the municipality.

If you start medication while you are an outpatient of the psychiatry service, your prescriptions will be issued where you are being treated, ready for you to take to the pharmacy. The staff of the department treating you are responsible for relevant subsidy applications and collaboration with your GP via the Shared Medication Record (FMK). If you are prescribed several different drugs at the same time, or if you have difficulty remembering to take your medication, dosette boxes or a blister pack dispensed by the pharmacy may help.

A lot of people are given slow-release medication, administered as an injection by the outpatient psychiatric treatment provision, the GP or a health centre. Arrangements are in place for special patient categories to receive medication free of charge. These free prescriptions are issued by agreement with the Region. Patients being treated under a court order can use this scheme, as can patients recently diagnosed with schizophrenia for the first two years. The free prescriptions scheme applies exclusively to antipsychotics – not to any other medication. The outpatient therapist of the psychiatric service takes care of prescriptions under the free scheme. The medication can be sent to the outpatient treatment centre, to the patient’s home, to the GP or to a health centre.

It is important to prevent relapse of psychosis. Relapse increases the risk that you will become less able to function socially, and you could lose your ability to deal with a number of tasks. You may find it more to deal with your daily activities, and there may be problems taking care of personal hygiene, and coping with cleaning, tidying and shopping. A relapse may mean a breakdown of relationships, as it becomes more difficult to hold down your job or continue studying and being around other people.

Stopping the medication is the most frequent cause of relapse. If you stop taking your medication within the first year, there will be a 75% risk of relapse. That is why it is important, at the very first psychotic episode, to examine whether there are factors that make it difficult to remember to take your tablets every day, and whether treatment with slow-release medication should be considered. To prevent a relapse, you work with early warning signs.

The same early warning signs often precede another psychotic episode. For that reason, it is important to know your early warning signs and to have prepared an emergency plan together with your therapist in the psychiatric service.

In the case of signs of relapse, consideration is given to whether external stress factors are a possible explanation, e.g. relationship breakdown, a very demanding study programme/work situation, substance abuse, etc. Another factor to be considered as potentially initiating a relapse is non-compliance with the doctor’s orders. Consideration is given to whether you might need help with taking your medication, such as a dosette box, dispensed blister packs from the pharmacy or mobile phone reminders when it is time to take your medication. The possibility of switching to slow-release medication could also be considered.