Phase Two Transition and Consolidation of Improvement

Once the psychotic symptoms have come under control, the second goal of treatment is to restore as much of the patient's premorbid function as possible. In general, this

TABLE 10.5. Recommended Dosing of First-Line Atypicals in Schizophrenia

Daily Dose in Acute Phase (Refined after Clinical Experience)

Risperidone: 2-6 mg/days Olanzapine: 10-20 mg/days Quetiapine: 300-800 mg/days Ziprasidone: 80-160 mg/days Aripiprazole: 10-30 mg/days phase of treatment involves resolution of acute-phase negative symptoms and cognitive impairments, and consolidation of improvement in positive symptoms. Negative symptoms typically improve slowly, over a period of 6 to 12 weeks, while cognitive and neuropsychological dysfunction show improvement for as much as 6 months to 1 year (Keefe et al., 1999). Critical elements of this phase of treatment are maintenance of compliance, optimization of medication dosage, solidification of a treatment alliance, and aggressive treatment of side effects. Obstacles to patient compliance include unacceptable side effects, denial of illness, lack of family and social support for treatment, and perceived social stigma associated with psychotropic medications. As noted in phase one, medications with superior side effect profiles are preferred. This is generally a period in which patients encounter significant changes or transitions in several aspects of their treatment: inpatient or partial hospitalization to outpatient, change in living situation, possible withdrawal of one or more acute-phase medications. Transitions are "dangerous times" in treatment, with a high risk of relapse, and hence should be as gradual as possible, with appropriate support provided as available.

At this stage of treatment, there may be a rational basis for selection of one atypical antipsychotic over another. As noted previously, the first-line atypicals differ primarily in side effect profile. The astute clinician will have identified the side effects of greatest concern to the particular patient by this stage of treatment and can then select the agent most favorable to the individual. A second issue to consider in this regard is the potential of antipsychotics (especially conventional agents) to contribute to negative symptoms, and for anticholinergic medications to worsen cognitive impairments. Balance must be achieved in maintaining resolution of psychotic symptoms, and in facilitating the progressive improvement of cognitive and negative symptoms. In general, atypical antipsychotics have substantial advantages over conventional neu-roleptics in this phase of treatment. Gradual cross titration (over 6 to 12 weeks) from one antipsychotic to another is the preferred strategy if patients are to be switched from one antipsychotic to another (Fig. 10.5). Psychosocial interventions are an integral part of treatment at this time. Patient and family education regarding the illness and its treatment are essential to ensure compliance, promote a return to social and f Atypical f Atypical a>

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Figure 10.5. Switching antipsychotics: Recommended strategy.

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Figure 10.5. Switching antipsychotics: Recommended strategy.

occupational function, and permit reasonable planning for future activities. This is also the most effective time to assess the patient's functional ability and make recommendations for social and vocational rehabilitation. Psychosocial treatment and pharmacologic interventions are interdependent for their success (Mojtabai et al., 1998).

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