Adjunctive Medication

Judicious use of additional medications may be appropriate in selected schizophrenic patients and is very frequently utilized. The basis for the use of adjunctive medication may be treatment of side effects, refractory psychotic symptoms, comorbid conditions, or specific nonpsychotic symptoms such as agitation, anxiety, depression, or mood elevation. Careful consideration of potential side effects, additive effects, and drug interactions is essential.

Anticholinergics. Anticholinergic agents effectively treat the EPS associated with first-generation 'conventional' neuroleptics. The justification for the use of anticholiner-gics with atypical antipsychotics is more limited. As noted previously, anticholinergics may contribute to cognitive deficits, as well as to peripheral side effects such as constipation, dry mouth, urinary retention, and blurred vision. Indications for use of anticholinergics with atypical antipsychotics include akathisia, rare EPS, and excessive salivation with clozapine.

Mood Stabilizers. Mood stabilizers have long been used in conjunction with antipsychotic medications to address concurrent mood symptoms or treatment refractory psychosis (Casey et al., 2001). Data in support of this practice are, however, sparse. Lithium has mood-stabilizing properties and can sometimes be useful for reducing excitement in patients suffering from schizophrenia. Valproate and other anti-convulsants are often employed (despite modest evidence of utility); they are beneficial in cases of mood elevation and may sometimes be helpful for persistent agitation. Adverse effects and impact on antipsychotic levels need to be monitored.

Benzodiazepines. Benzodiazepines are relatively benign agents useful in the treatment of agitation, insomnia, anxiety, and akathisia, all common concomitants of schizophrenia. Some evidence suggests that in agitated psychotic patients, lower total doses of antipsychotic may be used in the presence of benzodiazepines. The primary disadvantage of these drugs is the risk of abuse and dependency. They may also have a direct adverse effect on cognitive function.

Beta Blockers. Low doses of beta blockers can be useful in treating akathisia, which occurs in up to 20 percent of patients treated with conventional antipsychotics, and somewhat less commonly in patients treated with atypical antipsychotics.

Electroconvulsive Therapy (ECT). Electroconvulsive therapy should be considered in actively psychotic patients not responsive to other treatments. ECT is of clear, though short-term, benefit to many patients (Fink and Sackeim, 1996; Kales et al., 1999). Its safety in the presence of antipsychotic medications, including clozapine, is fairly well established.

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