Etiology of schizophrenia.
It is currently believed that the onset of schizophrenia is related to a variety of factors: personality traits, adverse events, stress, accidental factors, genetic factors, etc. The true cause is unknown. Schizophrenia and other psychiatric disorders are diseases of the brain. As the most complex organ: the brain, the internal structure is extremely complex, and the nerve cells of the brain, which are measured in billions, have an unusually complex connection with each other. It is now believed that there is an imbalance of neurotransmitters in the brain of schizophrenic patients, especially abnormalities of dopamine (DA) and 5-hydroxytryptamine (5-HT) are most related to schizophrenia. Then antipsychotic drugs can treat mental illness for this reason: they act on the brain’s neurotransmitter system to bring the brain’s neurotransmitters into balance and normal.
Classification of antipsychotic drugs.
1, according to the sequence of drug invention, divided into old drugs: chlorpromazine, fenazepam, sulpiride, clozapine, etc., and new drugs: olanzapine, aripiprazole, ziprasidone, quetiapine, amisulpride, risperidone, etc..
2. According to the pharmacological differences, they are divided into classical antipsychotics: chlorpromazine, haloperidol, sulpiride, etc. and non-classical antipsychotics: clozapine, olanzapine, risperidone, quetiapine, etc.
3. According to the dosage of drugs, they are divided into high potency drugs: haloperidol, endorphin, risperidone, etc., and low potency drugs: chlorpromazine, clozapine, quetiapine, etc. The way to differentiate is to look at the unit of each piece: if the dose of one piece is 1mg, 2mg is the high-efficiency drugs. If the dose is 25mg or 50mg, it is a low potency drug. Each of the two drugs has different pharmacological characteristics and clinical use precautions.
4, according to the drug’s length of action, and divided into long-acting drugs: only one oral long-acting drugs: pentafluoridol, tube a week, other long-acting drugs are injections: Halidol, Fluphenazine decanoate, Piperazine palmitate, Risperidone long-acting microspheres, etc., playing once can manage 2-4 weeks of the disease. And short-acting drugs: almost all oral drugs are short-acting drugs.
5, the price is different and divided into cheap drugs and expensive drugs. If the economic conditions are not good, eat cheap domestic drugs on the line, if the economic conditions are very good, then eat imported, imported drugs are slightly better quality, but domestic drugs are more cost-effective, we do not blindly believe in imported drugs.
Note: the efficacy of drugs and prices are not proportional, expensive drugs are not necessarily better.
6, according to the efficacy can be divided into good and general efficacy of the drug.
7, according to the size of the side effects can be divided into drugs with high and low side effects.
Therefore, to evaluate a drug, we should analyze it from several levels: efficacy? Price? side effects? Pharmacological characteristics? Each drug has its own advantages and disadvantages, and it is not a simple matter to choose the right antipsychotic drug and use it correctly.
I mainly evaluate drugs in terms of efficacy and side effects, after all, a drug with good efficacy and few side effects is the goal we all seek.
The key to determining efficacy is the pharmacological effect of the drug, which depends on the chemical structure formula of the drug.
How to use antipsychotic drugs.
According to the efficacy, dozens of antipsychotic drugs can be classified into three levels: best efficacy, better efficacy, and average efficacy. This is like the army, there are ace troops and general troops in the army, the ace troops are strong and always win battles, this ace troops are like the best antipsychotic drugs (ace drugs), of course, ace troops also defeat battles, used as a metaphor for the best efficacy of drugs sometimes can not cure patients, this is because there are individual differences in drug treatment, but in general the efficacy of ace drugs is the best, the most likely to cure the disease. This is because there is individual variation in medication, but in general, ace medication is the most effective and has the greatest chance of curing the disease.
Note: Regular blood tests, liver function, blood glucose, and electrocardiogram are required for any antipsychotic medication to detect problems and resolve them early.
Generally speaking, patients with a first episode tend to have good results, but if they have multiple relapses and a long course of illness, the more difficult it is to treat, and the results are often poor.
My medication ideas: the main thing is to choose the medication according to the patient’s condition.
1, if the patient is in the acute phase or relapse, symptoms are obvious, a lot of hallucinations and delusions, impulsivity, etc., or early use of strong drugs (ace drugs), in order to control the symptoms as soon as possible.
2.If the patient’s positive symptoms (hallucinations and delusions) are not obvious and the negative symptoms are heavy, you can consider choosing drugs with relatively good efficacy for the negative symptoms, such as amisulpride, sulpiride, aripiprazole, etc.
3. If the condition is stable and the side effects of the original drug are heavy, you can add drugs to relieve the side effects; you can also gradually reduce the amount of the original drug and switch to a drug with fewer side effects for maintenance treatment.
Several methods of medication
1, in general, the amount of medication should be slowly added, slowly reduced, the specific days to add or subtract, depending on the patient’s condition and the patient’s tolerance of the drug.
2, generally speaking, the principle of medication is a single use of drugs, systemic treatment: the amount of drugs to be enough, take enough time, the efficacy is not good, adjust the treatment plan: increase the amount, change the drug or a combination of drugs.
3, if a single use of a variety of drugs with different pharmacological effects is not effective, or side effects, the combination of drugs is also often used, and sometimes the combination of drugs will play a better effect.
The principle of combining drugs: do not combine drugs with similar pharmacological effects, but combine drugs with different pharmacological effects, combine high-efficiency drugs with low-efficiency drugs, and combine long-acting drugs with short-acting drugs. We hope to achieve the effect of 1+1>2.
Evaluation and analysis of antipsychotic drugs
For example, high potency drugs tend to cause extrapyramidal side effects, while low potency drugs tend to cause sleepiness and obesity, etc. We should not be afraid of talking about side effects, and we should not think that patients will get more and more stupid by taking them. We should face the side effects correctly, actively prevent them, actively deal with them, actively review the laboratory tests and examinations, actively observe the patient’s performance, actively respond to the patient’s complaints of discomfort and deal with them in a timely manner. Tolerating and accepting side effects is the price we have to pay if we want patients to recover. I will write a special article on the side effects of medications for you to read.
The ideal drug: good efficacy, no side effects, in fact, this is only ideal, any one drug can not cure all schizophrenia patients, as for side effects, there is no drug that can say no side effects.
I. Strong drugs (ace drugs) I want to introduce the ace drugs in detail.
1. Clozapine.
The world’s most effective antipsychotic drug is also the drug of choice for the treatment of refractory schizophrenia. Commonly used dose: 150-400mg/day.
When I was a trainee doctor, I followed the old director out of the clinic. The old director was over 70 years old (1996) and was one of the first psychiatrists in our country. My internship hospital is Jining Psychiatric Hospital, built in 1948, formerly a military hospital, had admitted soldiers suffering from mental disorders during the war against the U.S. and Korea, when I interned, the patients wore military uniforms, I often went to the mailroom at that time to get the class mail, a staff member of the hospital mailroom also wore a military uniform, it turned out that he was also a patient, hospitalized for quite a long time, and recovered well, let him in the mailroom Later, when he became familiar with him and talked about his condition, he told me that he was still taking clozapine to recover. Two examples are that before 2000, when there were fewer new non-classical antipsychotic drugs, clozapine was often used and had excellent efficacy, including when I first graduated, new patients were often treated with clozapine, which had good efficacy and few extrapyramidal side effects, and I often used it.
However, as the understanding of antipsychotic clozapine compounds deepens, new drugs continue to be used clinically, there is also a newer understanding of clozapine, my evaluation of him is: the incarnation of the angel and the devil, the angel is a metaphor for good efficacy, the devil is a metaphor for side effects. The side effects of clozapine: leukopenia, cardiac side effects: fast heart rate, affect heart function, affect blood sugar, constipation, drooling, drowsiness, obesity, etc. The incidence of these side effects is high and requires frequent leukocyte checks. How is clozapine currently used clinically? This drug is now a third-line drug, and is only considered for use at the end, mostly for refractory schizophrenia, or in combination with small doses. As long as the dose is applied appropriately and the side effects are controlled within an acceptable range, clozapine is still an excellent ace.
The same is true for the use of clozapine abroad, a third-line drug, mostly used for refractory schizophrenia. During the period of taking clozapine: when you first start taking it, check your blood count once a week, once every 2 weeks after 3 months, once every 1 month after 6 months, and then once every 3-6 months after a few years, in order to detect the most serious side effect of leukopenia early and deal with it early, and the leukopenia will be cured. After the invention of clozapine in the 1970s, there were a few deaths due to leukopenia in European patients, which resulted in the banning of clozapine in Europe, and it was only later that the use of clozapine was restarted. Better prevention of this side effect.
2, olanzapine.
From the name can be seen, olanzapine and clozapine is not a bit related ah, yes, clozapine and olanzapine in the chemical structure formula is very close, just like brothers. It has been used in psychiatric clinics in China for more than 10 years, and clinical practice has proven that the drug has excellent efficacy on both positive symptoms (hallucinations and delusions) and negative symptoms (withdrawal, withdrawal, laziness). The commonly used dose is 10-20mg/day, and individual patients may need to use 30mg, with far fewer side effects than clozapine. Common side effects include: sleepiness, obesity, high liver function, and individual female patients may also affect menstruation. Extrapyramidal side effects are small (extrapyramidal side effects are antipsychotic-induced hand tremors, high muscle tone, body tightness, inflexibility, fidgeting and other side effects). The price is also a disadvantage, 10mg imported is about 52 yuan more, the domestic 18 yuan more.
I admitted a young female patient in 1998, in her second year of college, diagnosed with schizophrenia, very serious condition, taking clozapine. 3 months later recovered very well, have been taking medication to maintain, in 2000 found out the white blood cell reduction, then switched to olanzapine, taking medication until now, 5mg per day, the patient successfully graduated from college, and later got a master’s degree, a doctor from Peking University, has graduated as a university teacher.
I am very fond of olanzapine, because most patients can recover better with this drug. In addition to the treatment of schizophrenia, for mania, and depression, olanzapine also has not bad performance, of course, olanzapine is not a panacea, but also for some patients will not be effective, ace army will also defeat the war?
Common side effects of olanzapine: abnormal liver function, sleepiness, obesity, abnormal blood sugar, abnormal menstruation in individual female patients, rare late onset dyskinesia. Timely review of the various laboratory tests, review the electrocardiogram, early detection of problems or easier to solve these problems.
3. Haloperidol.
This is an old drug, in Europe haloperidol is known as the “gold standard” of antipsychotic drugs, because this drug is effective, but he has a big problem: too easy to appear extrapyramidal side effects, patients are often uncomfortable, before adding to the treatment amount of serious side effects, long-term use is also prone to late-onset dyskinesia ( TD), these side effects seriously interfere with the use of haloperidol, if the patient can tolerate the side effects, often the efficacy will be better. The commonly used dose is 8-16 mg, right? It is said that foreign haloperidol is of good quality and has few side effects, just from what I have heard. Haloperidol has more long-acting injections of Harry, with fewer side effects, and is suitable for long-term maintenance treatment. 50-100mg once every 3-4 weeks intramuscularly.
Nowadays, for patients with severe excitement, short-term intramuscular injection of haloperidol is the most common and effective method. There is also electroconvulsive therapy. Some time ago there was a shortage of haloperidol injection, and we all said that psychiatry could not do it, which shows the importance of haloperidol injection in clinical practice. The reason is that there is really no other injection with good efficacy and low side effects except haloperidol injection.
By the way, risperidone is developed on the basis of haloperidol, and there is a certain relationship in the chemical structure, which is distantly related. Pentoxifylline and haloperidol belong to the same major class of drugs, the relationship is closer, is a close relative.
The key to determine the efficacy is the pharmacological effect of the drug, which depends on the chemical structure formula of the drug.
4. Amisulpride
Currently the latest domestic antipsychotic drugs, French research and development of drugs, there are studies show that its efficacy can be similar to olanzapine, clozapine, Europe with more, in the end how to need clinical verification. First of all, it is regarded as a kingpin drug, commonly used dose 400-1200mg/day, more expensive, 200mg about 19 yuan.
I have used a limited number of cases, is combined with olanzapine, the efficacy seems to be quite good.
400-600mg/day is better for negative symptoms and 800-1200mg/day is better for positive symptoms, so the information says.
I am very hopeful that this drug will have good efficacy, it has been a number of years since there was an ace drug with good efficacy.
The closest relationship to amisulpride is sulpiride, which is a close relative, but sulpiride has a weaker antipsychotic effect and works better for negative symptoms, with the biggest side effect of affecting lactogen, causing women to not have their periods. Sulpiride was originally developed as a treatment for nausea and vomiting, but was later found to have a role in treating schizophrenia.
For every patient, it doesn’t matter what kind of medication you take, as long as you are taking it with good results and few side effects, it is a good medication.
As for which medication is appropriate for each patient, we need to consider the patient’s condition, past medication experience and results after taking the medication, the patient’s tolerance of the medication, side effects, and the patient’s financial situation, and then make a decision after comprehensive consideration.
As a doctor, my heart will be filled with infinite pride and happiness.