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The word psychosis is used to describe conditions that affect the mind, causing a loss of contact with reality. Psychosis is most likely to occur in young adults and is quite common. Around three out of every 100 young people will experience a psychotic episode, making psychosis more common than diabetes in young people. Psychosis can happen to anyone. Like any other illness, it can be treated. Most make a full recovery.

Types of psychotic disorders include:

• Schizophrenia
• Schizophreniform disorder
• Schizophreniform
• Schizoaffective disorder
• Delusional disorder
• Brief psychotic disorder

Symptoms of psychosis

Psychotic disorders are characterized by hallucinations, delusions, personality disorganization, loss of ego boundaries and/or the inability to meet the ordinary demands of life. A person who is psychotic is out of touch with reality. The patient may "hear voices" or have strange and untrue ideas (for example, thinking that others can hear their thoughts, or are trying to harm them, or that the patient is the president of the United States or is some other famous person). The patient may get excited or angry for no apparent reason or spend a lot of time alone or in bed, sleeping during the day and staying awake at night. Patients may neglect their appearance, not bathing or changing clothes and may become difficult to communicate with, saying things that make no sense or barely talking at all. Symptoms vary from person to person and may change over time. The most common form of psychotic disorders is schizophrenia.

Antipsychotic medications work against these symptoms. These medications cannot "cure" the illness, but they can take away many of the symptoms or make them milder. In some cases, they can shorten the course of the illness as well.

There are a number of antipsychotic (neuroleptic) medications available. They all work. The main differences are in the potency, (the dosage prescribed to produce therapeutic effects) and side effects. Some people might think that the higher the dose of medication, the more serious the illness, but this is not always true.

A doctor considers several factors when prescribing an antipsychotic medication besides how "ill" someone is. These include:

• The patient's age
• Body weight
• Type of medication
• Past history

If a person took a particular medication before and it worked, the doctor is likely to prescribe the same one again. Some less potent drugs, like chlorpromazine (Thorazine®), are prescribed in higher numbers of milligrams than others of high potency, such as haloperidol (Haldol®).

If a person has to take a large amount of a "high-dose" antipsychotic medication, such as chlorpromazine, to get the same effect as a small amount of a "low-dose" medication, such as haloperidol, it may be difficult to understand why the doctor doesn't just prescribe "low-dose" medications. The main reason is the difference in their side effects. These medications vary in their side effects, and some people have more trouble with certain side effects than others. A side effect may sometimes be desirable. For instance, the sedative effect of some antipsychotic medications is useful for patients who have trouble sleeping or who become agitated during the day.

Unlike some prescription drugs that must be taken several times during the day, antipsychotic medications usually can be taken just once a day. Thus, patients can reduce daytime side effects by taking the medications before bed. Some antipsychotic medications are available in forms that can be injected once or twice a month, thus assuring that the medicine is being taken reliably.

Side effects

Most side effects of antipsychotic medications are mild. Many common ones disappear after the first few weeks of treatment. These include drowsiness, rapid heartbeat and dizziness when changing position.

Some people gain weight while taking antipsychotic medications and may have to change their diet to control their weight. Other side effects that may be caused by some antipsychotic medications include:

• Decrease in sexual ability or interest
• Problems with menstrual periods
• Easily sunburned
• Skin rashes

If a side effect is especially troublesome, discuss it with the doctor who may prescribe a different medication, change the dosage level or schedule, or prescribe an additional medication to control the side effects.

Muscular side effects

Movement difficulties may occur with the use of antipsychotic medications, although most of them can be controlled with an anti-cholinergic medication. These movement problems include muscle spasms of the neck, eye, back or other muscles; restlessness and pacing; a general slowing down of movement and speech; and a shuffling walk. Some of these side effects may look like psychotic or neurologic (Parkinson's disease) symptoms, but they aren't. If they are severe or persist with continued treatment with an antipsychotic, it is important to notify the doctor who might either change the medication or prescribe an additional one to control the side effects.

Ending treatment

Just as people vary in their responses to antipsychotic medications, they also vary in how quickly they improve. Some symptoms diminish in days while others take weeks or months. For many patients, substantial improvement is seen by the sixth week of treatment, although this is not true in every case. If someone does not seem to be improving, a different type of medication may be tried.

Even if a person is feeling better or completely well, medication should not be stopped without a doctor's supervision. Some people may need to take medication for an extended period of time or even indefinitely. These people usually have chronic (long-term, continuous) schizophrenic disorders or have a history of repeated schizophrenic episodes and are likely to become ill again. Also, in some cases, a person who has experienced one or two severe episodes may need medication indefinitely. In these cases, medication may be continued in as low a dosage as possible to maintain control of symptoms. This approach called maintenance treatment prevents relapse in many people and removes or reduces symptoms for others.

Maintenance treatment

While maintenance treatment is helpful for many people, a drawback for some is the possibility of developing long-term side effects, particularly a condition called tardive dyskinesia. This condition is characterized by involuntary movements. These abnormal movements most often occur around the mouth but are sometimes seen in other muscle areas such as the trunk, pelvis or diaphragm. The disorder may range from mild to severe. For some people, the condition cannot be reversed, while others recover partially or completely. Tardive dyskinesia is seen most often after long-term treatment with antipsychotic medications. There is a higher incidence in women, with the risk rising with age. There is no way to determine whether someone will develop this condition and if it develops, whether the patient will recover. At present, no effective treatment for tardive dyskinesia exists. The possible risks of long-term treatment with antipsychotic medications must be weighed against the benefits in each individual case by patient, family and doctor.

Medication interactions

Antipsychotic medications can produce unwanted effects when taken in combination with other medications. Therefore, the doctor should be told about all medicine being taken, including over-the-counter drugs and the use of alcohol. Some antipsychotic medications interfere with the action of anti-hypertensive medications (taken for high blood pressure), anticonvulsants (taken for epilepsy) and medications used for Parkinson's disease. Some antipsychotic medications add to the effects of alcohol and other central nervous system depressants, such as antihistamines, antidepressants, barbiturates, some sleeping and pain medications, and narcotics.

Neuroleptics

Typical neuroleptics (antipsychotics) are the traditional mainstay of treatment for psychosis. If someone refers to "older" antipsychotic medications, they are likely referring to the typical neuroleptics. These drugs block various dopamine receptors (nervous system chemicals) in the brain. In addition to limiting psychosis, lower dopamine levels also affect the motor system, causing unwanted muscular side effects.

Atypical antipsychotics

Since the introduction of Clozaril, several other newer generation antipsychotics have become available. These include Zyprexa® (olanzapine), Risperdal® (riseridone), Seroquel® (quetiapine), Geodon® (ziprasidone) and Abilify® (aripiprazole). This class, called atypical antipsychotics, now represent first-line treatments. These medications are as effective as the traditional antipsychotics, but they tend to be better tolerated. They are believed to work by balancing chemicals in the brain. Overall, the side effects are reduced. However, the problems associated with the traditional antipsychotics may be found less often with the newer medications. Some newer medications have been associated with weight gain and the development of diabetes.

FDA has asked manufacturers of all atypical antipsychotic drugs to add a warning to the drugs' labels about the increased risk of hyperglycemia and diabetes. Atypical antipsychotics include: Clozaril® (clozapine), Zyprexa® (olanzapine), Risperdal® (riseridone), Seroquel® (quetiapine), Geodon® (ziprasidone) and Abilify® (aripiprazole).

Epidemiologic studies suggest that the risk of hyperglycemia and diabetes is increased in patients taking Clozaril, Risperdal, Zyprexa and Seroquel, although the relationship isn't completely understood. In some cases, the hyperglycemia was extreme and associated with ketoacidosis or hyperosmolar coma or death. Geodon and Abilify weren't marketed at the time the study was conducted.

For some patients, the hyperglycemia went away when the drug was stopped, but others required continuing treatment for their diabetes even after they stopped taking the drug.

The warning recommends that patients with diabetes who are started on atypical antipsychotics be monitored regularly for worsening of glucose control.

Patients starting on these drugs who have diabetes risk factors, such as obesity or a family history of diabetes, should have fasting blood glucose testing at the start of treatment and periodically thereafter.

All patients treated with atypical antipsychotics should be monitored for symptoms of hyperglycemia, such as excessive thirst, excessive appetite, frequent urination, or weakness. If they develop symptoms of hyperglycemia while on these drugs, they should have a fasting blood glucose test.

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