Pharmacotherapy of mental disorders (psychopharmacotherapy) is one of the most dynamically developing areas of modern medicine. Over the past one and a half to two decades, new classes of psychotropic drugs have appeared and come into use, the ideas about the possibilities of treating a number of psychiatric disorders have radically changed, what yesterday seemed impossible today is becoming a daily practice. It is no longer a question of whether psychiatric disorders can be cured in principle, but about how to achieve results in a shorter time, with the least risk and with the lowest possible economic costs.
The common practice in most countries of the world in this direction has been the development and introduction of standards for the treatment of various groups of mental disorders, and the quality of treatment is defined as the degree of compliance with the generally accepted standard, rather than the opinion of certain specialists, as was customary in the national medical practice of the past. Such standards summarize the empirical experience (including the negative) of thousands of doctors, the results of rigorous scientific research, they take into account the economic potential of health care, the balance of expected costs and benefits, the degree of safety of treatment for the patient, the quality of his life during treatment, etc. It is understandable that these standards differ in different countries and vary in time. It should be noted that the introduction of standards is often not only recommendatory, but also directive in nature (for example, the Ministry of Health of the Russian Federation, No. 311, Model for the Diagnosis and Treatment of Mental and Behavioral Disorders, introduced in 1999, but it is still somewhat lagging behind.
The purpose of this article is to discuss modern standards for the treatment of schizophrenia and related disorders in general and in relation to today’s capabilities of the domestic psychiatric service in particular. As examples, we will refer to three versions of such standards that are in effect today in different countries of the world:
- An agreed guide to the treatment of schizophrenia by the US Committee of Experts in 1996 (hereinafter, for simplicity, we will refer to them as US standards);
- Clinical guidelines for the management of schizophrenia in primary and specialized care, developed by the National Institute for Clinical Excellence (NICE) (hereinafter referred to as their English standards);
- Operating in the Russian Federation “Models of diagnosis and treatment of mental and behavioral disorders” (hereinafter referred to as their Russian standards), which, for understandable reasons, are closest to the conditions of rendering psychiatric care in our country.
As is known, schizophrenia is a chronic mental illness whose prevalence is about 1% of the adult population; patients with schizophrenia occupy 50-60% of the beds of psychiatric hospitals
Severe economic damage from schizophrenia is associated with a high incidence of exacerbations – almost half of these patients are treated annually in hospitals. In the absence of treatment in 40-60% of patients exacerbation of psychosis occurs within the first 6 months. The risk of developing psychosis when using placebo reaches 10% per month, and with the use of neuroleptics it drops to 1% per month.
The main and most effective form of therapy for schizophrenic patients is the use of antipsychotics (antipsychotics). The therapeutic effect of these drugs is related to their ability to block postsynaptic dopamine receptors in the brain. Neuroleptics are conventionally divided into typical, or traditional (used since the mid-1950s), and atypical (newer, used since the 1980s), which are also called antipsychotics.
Typical (traditional) neuroleptics are divided into “weak” and “strong” (table). “Weak” neuroleptics (chlorpromazine, tizercin, sonapaks, chlorprotixen, teralen) have a predominantly sedative and not antipsychotic effect, they rarely cause extrapyramidal side effects (EPE). “Strong” typical neuroleptics (haloperidol, trifluoperazine, mazheptil, moden, etc.) have a pronounced antipsychotic effect, but they often cause EPE.
When using typical antipsychotics, a good therapeutic effect is observed in about 50%, a partial effect in 25% of patients; about 10% of patients do not give a therapeutic response in the first attack of the disease. Provided the correct use of neuroleptics and the use of other measures (working with the family, training the patient, etc.), the frequency of exacerbations during the first year of illness can be reduced to 15%.
Atypical antipsychotics (leponex, rispolept, olanzapine, etc.) have a strong antipsychotic effect and are much less likely than “strong” typical drugs to cause EPE in the early and middle term of treatment (up to 6 months). Atypical antipsychotics, unlike typical ones, affect both productive and negative symptoms of the disease – emotional flattening, apathy, social isolation, disruption of logical thinking, deterioration of cognitive functions, etc.
To correctly evaluate the effectiveness of therapy, to choose the right dose and reduce the risk of side effects, you should avoid the use of neuroleptic “cocktails”, ie, several antipsychotics at the same time. In other words, it is much better to use one drug in a sufficient dose than two or more. Only sometimes in cases of a combination of hallucinatory-delusional symptoms with pronounced excitation for a short time, two neuroleptics can be used simultaneously: one with sedation and the other with antipsychotic action (for example, tizercin + haloperidol, chloroprotoxen + trifluoperazine). Simultaneous administration of two drugs with predominantly antipsychotic effect (for example, haloperidol + trifluoperazine or haloperidol + mazheptil) or two drugs with sedative effect (for example, chlorpromazine + tizerincin or tizercin + chlorprotixen) is unacceptable. Simultaneously three or more neuroleptics are not used under any circumstances.
Atypical and typical antipsychotics should not be administered concomitantly, with the exception of short periods of treatment change, ie combinations of clozapine (azaleptin) + haloperidol or rispolept + chlorpromazine quite often found in domestic practice are erroneous by all standards.
In the absence of acute indications (for example, sharp psychomotor agitation, pronounced impulsiveness or aggression), the dose of neuroleptic is increased gradually (within 1-2 weeks) either until the therapeutic result is achieved or until pronounced side effects develop. At the same time, according to all specified standards, the dose of the drug should be not the maximum, the loading, but the least effective.