<unk> s are most frequently used for the following conditions: * Schizophrenia * Schizoaffective disorder most commonly in conjunction with either an antidepressant (in the case of the depressive subtype) or a mood stabiliser (in the case of the bipolar subtype). * Bipolar disorder (acute mania and mixed episodes) may be treated with either typical or atypical<unk> s, although atypical<unk> s are usually preferred because they tend to have more favourable adverse effect profiles and, according to a recent meta-analysis, they tend to have a lower liability for causing conversion from mania to depression. * Psychotic depression. In this indication it is a common practice for the psychiatrist to prescribe a combination of an atypical<unk>  and an antidepressant as this practice is best supported by the evidence. * Treatment resistant depression as an adjunct to standard antidepressant therapy.<unk> s are generally not recommended for treating behavioral problems associated with dementia, given that the risk of use tends to be greater than the potential benefit. The same can be said for insomnia, in which they are not recommended as first-line therapy. There are evidence-based indications for using<unk> s in children (e.g. tic disorder, bipolar disorder, psychosis), but the use of<unk> s outside of those contexts (e.g. to treat behavioral problems) warrants significant caution.<unk> s are used to treat tics associated with Tourette syndrome. Aripiprazole, an atypical<unk> , is used as add-on medication to ameliorate sexual dysfunction as a symptom of Selective serotonin reuptake inhibitor antidepressants in women. Quetiapine is used to treat generalized anxiety disorder. Schizophrenia<unk>  drug treatment is a key component of schizophrenia treatment recommendations by the National Institute of Health and Care Excellence (NICE), the American Psychiatric Association, and the British Society for Psychopharmacology. The main aim of treatment with<unk> s is to reduce the positive symptoms of psychosis that include delusions and hallucinations. There is mixed evidence to support a significant impact of<unk>  use on negative symptoms (such as apathy, lack of emotional affect, and lack of interest in social interactions) or on the cognitive symptoms (memory impairments, reduced ability to plan and execute tasks). In general, the efficacy of<unk>  treatment in reducing both positive and negative symptoms appears to increase with increasing severity of baseline symptoms. All<unk>  medications work relatively the same way, by antagonizing D2 dopamine receptors. However, there are some differences when it comes to typical and atypical<unk> s. For example, atypical<unk>  medications have been seen to lower the neurocognitive impairment associated with schizophrenia more so than conventional<unk> s, although the reasoning and mechanics of this are still unclear to researchers. Applications of<unk>  drugs in the treatment of schizophrenia include prophylaxis in those showing symptoms that suggest that they are at high risk of developing psychosis, treatment of first episode psychosis, maintenance therapy (a form of prophylaxis, maintenance therapy aims to maintain therapeutic benefit and prevent symptom relapse), and treatment of recurrent episodes of acute psychosis. Prevention of psychosis and symptom improvement Test batteries such as the PACE (Personal Assessment and Crisis Evaluation Clinic) and COPS (Criteria of Prodromal Syndromes), which measure low-level psychotic symptoms and cognitive disturbances, are used to evaluate people with early, low-level symptoms of psychosis. Test results are combined with family history information to identify patients in the "high-risk" group; they are considered to have a 20–40% risk of progression to frank psychosis within two years. These patients are often treated with low doses of<unk>  drugs with the goal of reducing their symptoms and preventing progression to frank psychosis. While generally useful for reducing symptoms, clinical trials to date show little evidence that early use of<unk> s improves long-term outcomes in those with prodromal symptoms, either alone or in combination with cognitive-behavioral therapy. First episode psychosis First episode psychosis (FEP) is the first time that psychotic symptoms are presented. NICE recommends that all persons presenting with first episode psychosis be treated with both an<unk>  drug, and cognitive behavioral therapy (CBT). NICE further recommends that those expressing a preference for CBT alone are informed that combination treatment is more effective. A diagnosis of schizophrenia is not made at this time as it takes longer to determine by both DSM-5 and ICD-11, and only around 60% of those presenting with a first episode psychosis will later be diagnosed with schizophrenia. The conversion rate for a first episode drug induced psychosis to bipolar disorder or schizophrenia are lower, with 30% of people converting to either bipolar disorder or schizophrenia. NICE makes no distinction between a substance-induced psychosis, and any other form of psychosis. The rate of conversion differs for different classes of drug. Pharmacological options for the specific treatment of FEP have been discussed in recent reviews. The goals of treatment for FEP include reducing symptoms and potentially improving long-term treatment outcomes. Randomized clinical trials have provided evidence for the efficacy of<unk>  drugs in achieving the former goal, with first-generation and second generation<unk> s showing about equal efficacy. Evidence that early treatment has a favorable effect on long term outcomes is equivocal. Recurrent psychotic episodes Placebo-controlled trials of both first and second generation<unk>  drugs consistently demonstrate the superiority of active drug to placebo in suppressing psychotic symptoms. A large meta-analysis of 38 trials of<unk>  drugs in schizophrenia acute psychotic episodes showed an effect size of about 0.5. There is little or no difference in efficacy among approved<unk>  drugs, including both first- and second-generation agents. The efficacy of such drugs is suboptimal. Few patients achieve complete resolution of symptoms. Response rates, calculated using various cutoff values for symptom reduction, are low and their interpretation is complicated by high placebo response rates and selective publication of clinical trial results. Maintenance therapy The majority of patients treated with an<unk>  drug will experience a response within four weeks. The goals of continuing treatment are to maintain suppression of symptoms, prevent relapse, improve quality of life, and support engagement in psychosocial therapy. Maintenance therapy with<unk>  drugs is clearly superior to placebo in preventing relapse but is associated with weight gain, movement disorders, and high dropout rates. A 3-year trial following persons receiving maintenance therapy after an acute psychotic episode found that 33% obtained long-lasting symptom reduction, 13% achieved remission, and only 27% experienced satisfactory quality of life. The effect of relapse prevention on long term outcomes is uncertain, as historical studies show little difference in long term outcomes before and after the introduction of<unk>  drugs. While maintenance therapy clearly reduces the rate of relapses requiring hospitalization, a large observational study in Finland found that, in people that eventually discontinued<unk> s, the risk of being hospitalized again for a mental health problem or dying increased the longer they were dispensed (and presumably took)<unk> s prior to stopping therapy. If people did not stop taking<unk> s, they remained at low risk for relapse and hospitalization compared to those that stopped taking<unk> s. The authors speculated that the difference may be because the people that discontinued treatment after a longer time had more severe mental illness than those that discontinued<unk>  therapy sooner. A significant challenge in the use of<unk>  drugs for the prevention of relapse is the poor rate of adherence. In spite of the relatively high rates of adverse effects associated with these drugs, some evidence, including higher dropout rates in placebo arms compared to treatment arms in randomized clinical trials, suggest that most patients who discontinue treatment do so because of suboptimal efficacy. If someone experiences psychotic symptoms due to nonadherence, they may be compelled to treatment through a process called involuntary commitment, in which they can be forced to accept treatment (including<unk> s). A person can also be committed to treatment outside of a hospital, called outpatient commitment.<unk> s in long-acting injectable (LAI), or "depot", form have been suggested as a method of decreasing medication nonadherence (sometimes also called non-compliance). NICE advises LAIs be offered to patients when preventing covert, intentional nonadherence is a clinical priority. LAIs are used to ensure adherence in outpatient commitment. A meta-analysis found that LAIs resulted in lower rates of rehospitalization with a hazard ratio of 0.83, however these results were not statistically significant (the 95% confidence interval was 0.62 to 1.11). Bipolar disorder<unk> s are routinely used, often in conjunction with mood stabilisers such as lithium/valproate, as a first-line treatment for manic and mixed episodes associated with bipolar disorder. The reason for this combination is the therapeutic delay of the aforementioned mood stabilisers (for valproate therapeutic effects are usually seen around five days after treatment is commenced whereas lithium usually takes at least a week before the full therapeutic effects are seen) and the comparatively rapid antimanic effects of<unk>  drugs. The<unk> s have a documented efficacy when used alone in acute mania/mixed episodes. Three atypical<unk> s (lurasidone, olanzapine and quetiapine) have also been found to possess efficacy in the treatment of bipolar depression as a monotherapy, whereas only olanzapine and quetiapine have been proven to be effective broad-spectrum (i.e. against all three types of relapse—manic,
Antipsychotic
Mood stabilizer
Antidepressant
Antimanic drugs
Appetite stimulant
Tricyclic antidepressant
Tetracyclic antidepressant
Atypical antidepressant