Recovery From Schizophrenia: Psychiatry And Political Economy

240 TREATMENTmedications; the appropriate way to treat the resulting agitation is by reducing orchanging the neuroleptic drug or by prescribing enough side-effect medicine.Sometimes the new symptoms are more psychological in nature and are a resultof hysteria or dependency, in which case an increase in antipsychotic medicationis not appropriate.When a patient is in an acute psychotic episode use minor tranquilizers, not heavy dosesof antipsychotic medication, to reduce agitation and other acute symptoms (see below). Ingeneral, acutely disturbed patients should only be given the dosage ofantipsychotic medication that they would ordinarily need as a maintenance dosewhen they are doing well. In acute treatment in the hospital, however, muchbigger doses of the antipsychotic medications are often given, sometimes resultingin severe side effects; the subsequent reduction in dosage when the patient hasrecovered from the acute episode may take much longer than necessary.When a patient is stable, try and establish the lowest dose of medication that keeps theworst aspects of the illness at bay without causing intolerable side effects. This can be doneby cautiously reducing the dosage every few weeks or months. Once this dosagehas been established, it may be necessary to stay at that level for an extendedperiod of time.MINOR TRANQUILIZERS IN SCHIZOPHRENIAPeople with acute schizophrenia who are overactive and excited or at risk ofhurting others, attempting suicide or running away from treatment may often behelped in the short run by the use of moderate doses of the minor tranquilizers inaddition to neuroleptic medication. The belief used to be widespread inpsychiatry that the minor tranquilizers, including the benzodiazepine drugs,diazepam (Valium) and lorazepam (Ativan), were harmful or at best worthless inpsychosis. This is not the case. These drugs are often effective in calming agitatedpsychotic patients—more immediately so, in fact, than the antipsychotic drugs. Insome cases they even have a prompt antipsychotic action.The effectiveness of the benzodiazepines in such cases is probably due to areduction in the patient’s level of arousal. It is also likely that the benzodiazepinesexert an antipsychotic effect by their action in blocking dopamine release. Theymay achieve this effect by stimulating a feedback loop (in which theneurotransmitter is gamma-amino butyric acid) that damps down the release ofdopamine. 68 Several reports have shown that the benzodiazepines in moderate orhigh doses, alone or in combination with neuroleptic drugs, are effective incontrolling psychotic symptoms. 69 Somewhat fewer studies have found them tobe ineffective or to produce equivocal results. 70 On balance, it appears that thebenzodiazepines are sometimes effective over longer periods of time for peoplewith schizophrenia but, without doubt, they are most useful in calming theacutely disturbed patient and in the acute treatment of the person with catatonicschizophrenia who is immobilized by a high internal level of arousal. 71