Poisonings with antipsychotic agents (unlike tricyclic antidepressants) are rarely fatal, with the exception of those due to mesoridazine and thioridazine. In general, drowsiness proceeds to coma, with an intervening period of agitation. Neuromuscular excitability may be increased and proceed to convulsions. Pupils are miotic, and deep tendon reflexes are decreased. Hypotension and hypothermia are the rule, although fever may be present later in the course. The lethal effects of mesoridazine and thioridazine are related to induction of ventricular tachyarrhythmias. Patients should be given the usual “ABCD” treatment for poisonings (see Chapter 58) and treated supportively. Management of overdoses of thioridazine and mesoridazine, which are complicated by cardiac arrhythmias, is similar to that for tricyclic antidepressants (see Chapter 30).
Patients with schizophrenia need psychosocial support based around activities of daily living, including housing, social activities, returning to school, obtaining the optimal level of work they may be capable of, and restoring social interactions. Unfortunately, funding for this crucial component of treatment has been minimized in recent years. Case management and therapy services are a vital part of the treatment program that should be provided to patients with schizophrenia. First-episode patients are particularly needful of this support because they often deny their illness and are noncompliant with medication.
Benefits & Limitations of Drug Treatment
As noted at the beginning of this chapter, antipsychotic drugs have had a major impact on psychiatric treatment. First, they have shifted the vast majority of patients from long-term hospitalization to the community. For many patients, this shift has provided a better life under more humane circumstances and in many cases has made possible life without frequent use of physical restraints. For others, the tragedy of an aimless existence is now being played out in the streets of our communities rather than in mental institutions.
Second, these antipsychotic drugs have markedly shifted psychiatric thinking to a more biologic orientation. Partly because of research stimulated by the effects of these drugs on schizophrenia, we now know much more about central nervous system physiology and pharmacology than was known before the introduction of these agents. However, despite much research, schizophrenia remains a scientific mystery and a personal disaster for the patient. Although most schizophrenic patients obtain some degree of benefit from these drugs—in some cases substantial benefit—none are made well by them.
■ LITHIUM, MOOD-STABILIZING DRUGS, & OTHER TREATMENT FOR BIPOLAR DISORDER
Bipolar disorder, once known as manic-depressive illness, was conceived of as a psychotic disorder distinct from schizophrenia at the end of the 19th century. Before that, both of these disorders were considered part of a continuum. The weight of the evidence today indicates that there is profound overlap in these disorders. However, there are pathophysiologically important differences, and some drug treatments are differentially effective in these disorders. According to DSM-IV, they are separate disease entities while research continues to define the dimensions of these illnesses and their genetic and other biologic markers.
Lithium was the first agent shown to be useful in the treatment of the manic phase of bipolar disorder that was not also an anti-psychotic drug. Lithium is sometimes used adjunctively in schizophrenia. Lithium continues to be used for acute-phase illness as well as for prevention of recurrent manic and depressive episodes.