In the case of clearly diagnosed schizophrenia.
(1) In first cases, there is hope for complete cure. Don’t be afraid of fat and expensive drugs. In fact, short-term application of olanzapine is the most effective treatment currently available and the most inexpensive, usually as little as $2,000 to $3,000, to solve the problem. There are many cases, starting with risperidone, switching to quetiapine, then to aripiprazole, and then to ziprasidone, and finally to olanzapine, before solving the problem. It can be said that if olanzapine treatment is ineffective, it is of little use to switch to other drugs. Therefore, seize the opportunity to treat as follows.
Olanzapine can be taken in one step, without having to gradually increase the dosage. Start by taking 10mg every night for 2 days. See if there is any special reaction other than drowsiness. If not, you can take 20mg per night, one dose from day 3 onwards. This way, you sleep well at night and do not get drowsy during the day. Continue treatment for 2 weeks. If the effect is seen, hallucinations and delusions are reduced or disappear, then continue to consolidate for 2-3 weeks. If no effect is seen, increase the dose to 30mg per night and continue for 2 weeks. If the effect is seen and the hallucinations and delusions are reduced or disappear, the treatment will be continued for 2-3 weeks. Thereafter, the dose can be reduced by 5mg every 2 weeks on a trial basis; feel the stones and cross the river. If symptoms return, you can return to the original dose. That’s it …… Until the reduction to 5mg per night, two maintenance options are available: one, long-term maintenance with olanzapine 5mg (or 2.5mg). The other method is to add pentoxifylline at this point, overlapping the two for 2 weeks as a ‘handover shift’, after which the olanzapine is discontinued and the pentoxifylline is kept on.
Short-term application of olanzapine, possible side effects are: 1) drowsiness: drowsiness may be heavy at first, do not pay attention to it, as long as get up more slowly to prevent upright hypotension; after a few days, will gradually adapt. 2) individual patients may have ‘sitting still can not’ (note), at this time, you can take Benadryl (Antan), 2 times a day, 1 tablet each time 3) Increased appetite: Weight gain can be prevented by controlling the diet as much as possible. Olanzapine is similar to clozapine and generally does not produce significant Parkinson’s-like side effects. (Note: Inability to sit still is a common side effect of antipsychotics and is not ‘walking around without a purpose’. Patients themselves have full self-awareness of their inability to sit still, and will complain that they feel restless, that they feel ‘wrong to stand, wrong to sit’, ‘wrong to walk horizontally, wrong to walk vertically’, and that they seem to have ‘eighteen buckets and Seven up and eight down’. Sometimes, standing there, like ‘stepping’, the left foot and right foot keep changing in turn. Sometimes, he complains of ‘itchy heart’ and ‘itchy bones’, and is mistaken by doctors for somatic hallucinations).
There are three ways to take pentoxifylline, and the third way is the best, with no side effects at all; however, do not take ‘1 tablet (20mg) at a time every week:’
1) Half a tablet (i.e. 10mg) twice a week;
2) 1 quarter tablet (i.e. 5mg) every other day;
3) Grind 20mg of pentoxifylline into powder, divide it into 7 or 8 portions, divide it into paper packets and take 1 packet orally every day.
Why do I choose pentoxifylline as a long-term maintenance medication? Because it does not have drowsiness, does not increase weight, does not increase blood sugar, does not increase blood lipids, especially does not induce compulsion, and is inexpensive, costing only $5 per month. Some doctors say that pentoxifylline is an old drug that has been eliminated and has serious side effects, so they dare not apply it. In fact, this is the problem of taking method. If you don’t take 1 tablet (20mg) every week, but take it in divided doses according to the above method, you won’t be able to ‘sit still’. In many cases, there are no side effects from taking such a small amount of medicine and maintaining a normal life and work for more than 10 years. It should be said that as long as one uses pentoxifylline honestly as maintenance, all of them will not relapse. Among my thousands of cases, there are a few cases of relapse; however, it is not the efficacy of the drug, but the fact that the pills were actually kept in the patient’s mouth and spit out. Therefore, I usually advise the patient to grind up the tablets and let the patient swallow them at once, not allowing him to keep them in his mouth.
Of course, pentoxifylline, like other antipsychotics, has a very small number of patients (in thousands of cases, I have met three or four cases) who become depressed after taking it, and then antidepressants such as fluoxetine should be added.
(2) If it is a case with many years of illness and repeated treatment, you can also try the above treatment, but there is not much hope. If you have not done electrotherapy, you can try MECT. it should be said that MECT has no adverse effects, only in 2-3 months after treatment, memory is poor, but in 3 months can certainly be completely back to normal. Patients are advised to write down passwords, passbooks, etc., in advance to avoid trouble before treatment.
(3) If olanzapine treatment is applied and the dose is increased to 20 or 30 mg per night, and still no effect is seen, and you do not want to do MECT, you can try to combine the drugs. In my opinion, it is not advisable to apply olanzapine with those clozapine, risperidone, quetiapine, or ziprasidone, which are pharmacologically similar to it; because they are similar and cannot play a complementary role. It seems that olanzapine can be combined with different classes of antipsychotics, such as haloperidol, sulpiride, and pentoxifylline; they have the potential to complement each other. I have had some cases where the symptoms were significantly better after using pentoxifylline.
(4) If the symptoms do not disappear completely even after using MECT, and if the problem is not completely solved, you can only be realistic and face the reality and use medication maintenance. The type of medication varies from person to person, and can be maintained with a small amount of olanzapine, or clozapine, or other 2nd generation antipsychotics, plus pentafluoridol. For them, the family must supervise the medication because self-awareness is not sufficiently recovered. In addition to pentafluridol, aripiprazole, or sulpiride, can be used for maintenance. However, sulpiride, or amisulpride should not be used in female patients because they have the potential to affect menstruation and fertility. Some patients have been maintained on small doses of clozapine and are doing well, so it does not seem necessary to replace them.
(5) In some patients, although self-knowledge has been restored after treatment, the hallucinations and delusions have still not completely disappeared; at this point, a ‘peaceful coexistence’ attitude can be adopted. I have some cases that are like this, working and living normally with a little hallucinations. In one case, after treatment, although the delusion that he was framed by his father did not disappear completely, he was able to take his medication voluntarily and live and work normally; when talking about the delusion, he said, “I can live with my father in peace, and I will not pursue what happened before.
In case of depression.
Early application of antidepressants. The key is to 1) get the right dose, if 1 tablet is not enough, use 2 tablets; just like eating, if 1 bowl is not enough, don’t hesitate to take 2 bowls. 2) pick the drug with the least side effects. 3) take it for at least 6 months, a year is better, to prevent relapse.
My habit is to apply fluoxetine, not that it is the best and the only one; only because it is the most ‘oldest’; 70 million people around the world have taken it, and it has proved to be safer, with very few side effects, effective and inexpensive. I don’t believe that a certain drug works fast and a certain drug works slow. In fact, the pharmacological effects of antidepressants occur very quickly, so why should there be a delay before the condition gets better? That depends on the recovery process of the organism; the recovery process is fast or slow and varies from person to person. Thus, it seems that it is not the drug, but the person that is responsible for the fast and slow onset of action. I found that in some cases, it took 3 weeks to work with this drug, and in the second relapse, it took 3 weeks to work with another drug that was supposedly fast-acting.
In my opinion, one should never use risperidone, olanzapine, quetiapine, etc. as ‘booster’ to treat depression. In fact, it is counterproductive and they can all trigger ‘pharmacogenic depression’!
If you use fluoxetine, 40mg per day, and still no effect, you can add mirtazapine, first try half a tablet per night, if there are no adverse effects, you can increase to 1 tablet per night. If it does not work again, you can switch to SNRI, or add Maprotiline or Reboxetine on top of Fluoxetine. If the depression is really difficult to treat, it can be treated with MECT.
In case of manic-depressive disorder (bipolar).
Nowadays, some doctors tend to diagnose ‘biphasic’ as soon as they hear ‘impulsivity’ or ‘tantrums’, thinking that they are ‘excited ‘; in fact, this is not the case. If it is biphasic, it should manifest in cycles: depressed mood for one or two weeks, return to normal, and later a high mood for one or two weeks, …. ;Of course, the cycle may be long or short, and the degree may be mild or severe, but ‘periodicity’ is a necessary feature. More importantly, there should be no symptoms remaining between episodes and full self-knowledge. If indeed it is truly ‘biphasic’, then it should be treated with lithium carbonate, sodium valproate, or carbamazepine. For sodium valproate, typically 0.4 g twice daily (i.e., 2 tablets); maintenance doses are at least 3 tablets daily. The number of tablets of lithium carbonate is similar to that of sodium valproate, and the dose can be determined more by the blood lithium concentration. For manic-depressive disorder, it may be necessary to take the medication for life to prevent relapse.
If the mood is too excited and really uncontrollable (because lithium carbonate or sodium valproate and other drugs ‘can not quench the thirst of the near’, it must be more than 2 weeks before the effect), you can first use clozapine, olanzapine, risperidone, quetiapine and other drugs to suppress the excited mood. However, in my opinion, they are not a possible substitute for mood stabilizers such as lithium carbonate, and should be reduced early, until discontinued, after excitement is controlled. One is to try to avoid unnecessary side effects (especially TD), and the other is to test whether the diagnosis of ‘bipolar’ is reliable. If the condition does not deteriorate with the use of mood stabilizers alone at this time, the diagnosis of ‘bipolar’ can be confirmed; otherwise, the diagnosis of ‘bipolar’ cannot be relied upon and is likely to be schizophrenia. By the way, these so-called ‘mood stabilizers’ are only applicable to the treatment of manic-depressive disorder (bipolar) and the prevention of relapse, and they do not have a stabilizing effect on any mood, so doctors and patients should not misunderstand and use them indiscriminately.
MECT can accelerate the control of arousal, but it still needs mood stabilizers to maintain the treatment.
In case of obsessive-compulsive disorder.
OCD is a very stubborn and difficult disease to treat, be patient. Clomipramine, at least 6 tablets or more to be effective; it has more side effects and is often tolerated. In my opinion, it is better to use fluoxetine, there are no side effects. The key is: 1) the dose needed is relatively large, at least 40mg per day (i.e. 2 capsules), some need to add up to 3 or 4 capsules to be effective. Some doctors use sertraline, then at least 4 capsules (200mg) or even more. 2) It takes longer, often 3-4 weeks to start seeing results. After the effect is seen, continue the treatment. Continue the medication for at least 12 years and see how it goes; it may be necessary to take the medication for life to prevent relapse. Never use risperidone, olanzapine, quetiapine, etc. as ‘boosters’ to treat OCD. In fact, they are counterproductive and can trigger ‘pharmacogenic OCD’!
If you have already used risperidone, olanzapine, quetiapine and other drugs, you should stop using them immediately; otherwise the OCD is unlikely to get better. Just as it is impossible to cure OCD while on clozapine, which must be stopped first.
As for psychosurgery, I was the first person in China to try to treat OCD with stereotactic surgery. I worked with a hospital neurosurgery department and treated 23 cases back in the 1980s, 18 of which were effective, but all relapsed within 3 months and were finally treated with medication. For this reason, I have communicated with foreign specialists, and their experience is the same. Therefore, I think this treatment method is not mature enough at present.
In the case of schizophrenia with obsessive-compulsive symptoms.
I believe that schizophrenia itself does not contain the component of obsessive-compulsive symptoms. The presence of compulsions in schizophrenic patients is necessarily all caused by antipsychotics (note). Clozapine, risperidone, olanzapine, quetiapine, ziprasidone, all induce obsessive-compulsive symptoms to varying degrees. When obsessive-compulsive symptoms occur, these medications must first be discontinued and replaced with an antipsychotic that does not trigger obsessions, such as haloperidol, sulpiride, or pentafluridol. In the meantime, fluoxetine was given at 40 mg per day, or more, as per the treatment for OCD. It also seems to be taken for a long time, several years or more.
(Note: How exactly do you distinguish schizophrenia from OCD? I think the most important thing to figure out is: do the obsessive-compulsive symptoms come first, or do the psychotic symptoms such as hallucinations and delusions come first? After observing so many clinical cases over the years, I can say with certainty that schizophrenia itself does not include obsessive-compulsive symptoms. I have read many original foreign psychiatric texts. Before the introduction of chlorpromazine (1952), no book or article ever mentioned that schizophrenic patients had obsessive-compulsive symptoms; if you don’t believe me, check out the works of Krapelin, Blueler, or Schneider. It was only after the 1950s, when chlorpromazine was introduced, that schizophrenic patients were found to exhibit obsessive-compulsive symptoms. Old Professor Yu Ching-Han of Xi’an, who was perplexed by this problem during his lifetime, wrote several articles to me, arguing that ‘it is incredible that schizophrenia could become obsessive-compulsive disorder’. In fact, all these cases were obsessive-compulsive disorder caused by drugs like chlorpromazine. They are less strongly listed for this effect, so the number of cases is small. Nowadays, the second-generation antipsychotics such as clozapine and risperidone have stronger OCD-inducing effects, and cases of OCD are common and well known. Therefore, it should be possible to conclude that schizophrenia itself does not include obsessive-compulsive symptoms; if they occur during the course of the illness, they are induced by antipsychotic drugs. There is, of course, the opposite possibility: if one has had obsessive-compulsive symptoms for many years and later develops psychotic symptoms, such as hallucinations and delusions, and if they meet the diagnostic criteria, one can certainly make the diagnosis that “the person with OCD is suffering from schizophrenia”. After all, there is a 1% chance that a person with OCD will develop schizophrenia.