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Schizoaffective Disorder Treatments

I was diagnosed with schizophrenia 24 years ago (I am 43 now). By some standards I would be considered high functioning. I completed a Master’s in chemistry, am married and have a job working nights so I do not have to be around too many people. I did well for many years, but recently it’s been more difficult. I have been hospitalized four times in the past two years. I take my medications (Haldol, Zyprexa, Cogentin, Wellbutrin and occasionally, Ativan) and although I do not hear voices very often now, I have perceptions and receive unwanted messages. Other medications I have tried in various combinations (but found less helpful than my current combo) are Navane, Seroquel, Clozaril, Risperdal, Stelazine, Serzone, Celexa, Zoloft and Paxil. All of the antidepressants except Wellbutrin made the voices worse. Do you have any suggestions? My psychiatrist is generally very open to ideas and suggestions.

It sounds like you have done very well in both your social and vocational life, despite the burden of a serious disorder. I am certainly not in a position to recommend any specific course of treatment for you; and even if I were, I am not at all sure I’d be eager to rock the boat, given how well you have done overall. This is not to minimize the distress you may feel when you do experience abnormal perceptions or unwanted messages, and I do appreciate that the four hospitalizations represent a setback for you.

Given these caveats, maybe it would be helpful to review some general treatment options that are often used, or are being investigated, for refractory schizophrenia. (By the way, some of your medications raise the question of whether “schizoaffective disorder” might better characterize your diagnosis, since you seem to require an antidepressant, but I am not in a position to reach any diagnostic conclusions).

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First, it is always worth reassessing the dose and blood level of an antipsychotic. Thus, if a patient is getting 60% improvement taking, say, 15 mg per day of olanzapine (Zyprexa), it may be worth trying 20 or 25 mg per day, though side effects (e.g., tremor, dry mouth) may increase somewhat as the dose goes higher. (Some clinicians will go as high as 30-35 mg/day with Zyprexa; my colleagues and I have observed a few cases of increased agitation at these higher doses, however). Checking a blood level can be useful to ensure that the patient is absorbing the medication adequately, though therapeutic blood levels are not well-established with Zyprexa.

The same considerations would apply to dosage of an adjunctive antipsychotic, such as haloperidol (Haldol), which actually does have a well-described therapeutic level of between 4-15 ng/ml. If a patient were getting modest benefit from Haldol with a blood level of, say, 5-6 ng/ml, it might still be worth increasing the dose a bit. (Again, side effects may increase at higher doses). Since there is some evidence that benzodiazepines (such as lorazepam/Ativan) may have an adjunctive benefit in schizophrenia, it is worthwhile considering using a “standing” (daily) dose of a benzodiazepine instead of taking it now and then. Of course, the risks of dependency on benzodiazepines must be considered, but for individuals without an alcohol or substance abuse history, the risks are modest. We are expecting that in the next 6-12 months, a new antipsychotic with possible antidepressant properties–ziprasidone (Zeldox), will become available in the U.S. This would certainly be worth considering in patients whose schizoaffective or schizophrenic illness has not responded adequately to other atypical antipsychotics.

There is also increasing interest in the use of omega-3-fatty acids (found in tuna, fish oil, etc.) for both bipolar disorder and for schizophrenia, though research on this is in its infancy. (Still, eating more tuna is not likely to do anybody much harm!). Of course, having a supportive psychotherapeutic relationship with a mental health professional is also very important in the treatment of schizophrenia and related disorders. Sometimes, even a reassuring call can help mute a patient’s preoccupation with voices and other symptoms. In the end, the most constructive suggestion I can pass on to you and your doctor is to seek a face-to-face consultation with a recognized expert in the area of psychotic illness, usually best obtained via an academic medical center. Good luck!

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