Management of the Refractory Psychotic
Vernon M Neppe MD, PhD
To educate in the area of refractory, atypical and nonresponsive
psychosis, particularly the clinical psychopharmacologic management.
To create a workable outline with regard to management options
The patient with refractory psychosis is particularly difficult to treat.
These patients have invariably failed trials of several neuroleptics.
Their treatments of necessity go beyond FDA approved indications and
are still being researched.
A specific treatment approach is outlined in my book
First ensure compliance, if necessary with short-acting
intramuscular injection or with depot neuroleptics.
Second, evaluate toleration of antipsychotic doses on the basis
of extrapyramidal, hypnogenic, and autonomic side-effects.
Non-toleration implies organic disease, often hyperthyroidism.
Third, test the limits of appropriate neuroleptic: low doses in some
instances are suitable, high doses in others particularly chronic
Fourth, recognize that not all neuroleptics are equal. Clozapine
is especially topical and difficult to use. Unmarketed drugs such
as sulpiride and pipothiazine are especially interesting. Each drug
has special effects at several different receptors.
The major approach, however, is to seek out target features. Add
medication usually as adjunct to neuroleptic to treat these target
Carbamazepine may be useful in hostility, lability, temporal
lobe pathology and previous hallucinogens. Other anticonvulsants
may at times have roles.
Lithium and antidepressants have applications in affectively
Anticholinergics have special roles in possible akathisia and
Propranolol and other beta 2 active drugs such as nadolol have roles
in significant anxiety.
Benzodiazepines can be used in mania, catatonia, for nonspecific
sedation and in epileptics.
Nutrition elements are important as is the special role of
caffeine, cigarettes and drugs of abuse.
Levodopa is particularly interesting in the catatonic patient
and has special implications for dopamine research.
Buspirone may have a special role in tardive dyskinesia, tardive
psychosis, possible tardive prophylaxis, irritability and
obsessionality. The doses may be critical. There may be a link of
serotonin 1A and dopamine.
Using this framework, a fascinating and apparently successful
intervention plan can be developed.
© Copyright 1997 Pacific Neuropsychiatric Institute.