ASHP Therapeutic Position Statement on the Use of Second-Generation Antipsychotic Medications in the Treatment of Adults with Psychotic Disorders
Individuals with schizophrenia generally exhibit a mixture of positive, negative, and cognitive symptoms with varying intensity throughout the course of their illness (Table 1). Schizoaffectivedisorder differs from schizophrenia in that recurrent mood episodes (mania or depression) occur over a substantial period of time over the course of the illness in addition to chronic psychotic symptoms. These two disorders have been studied together in many clinical trials and will be considered together for the purpose of this document. It has been estimated that the worldwide lifetime frequencyof psychotic disorders is about 1%.2,3 Onset of the first severe psychotic symptoms in a patient with schizophrenia usually occurs between the late teens and mid-30s, with onset in males peaking between ages 15 and 30 and females exhibiting a later onset, between ages 20 and 35.4,5 Late-onset schizophrenia, occurring after 40 years of age, may have an otherwise similar course to typicaladult-onset schizophrenia. Prodromal symptoms of psychosis occurring in children and adolescents (e.g., apathy, social withdrawal) may be present before the first psychotic break, but the full symptoms of these disorders are rare in this population. Because these illnesses frequently have their symptom onset in early adulthood and are characterized by a wide range of symptoms, they usually causesignificant, progressive impairment in the social, occupational, and academic functioning of affected individuals.
The American Society of Health-System Pharmacists (ASHP) recognizes that schizophrenia, schizoaffective disorder, and other psychotic disorders are serious mental illnesses that can significantly affect an individual’s perceptual, behavioral, affective, and cognitive functions. Theseconditions are usually chronic and recurrent, necessitating continuous treatment over the patient’s lifetime. Individuals with these disorders frequently require lengthy and expensive hospitalizations, as well as a variety of ongoing rehabilitative and supportive services that can impose a significant burden on society. In addition, high rates of suicidal behavior and completed suicides have been observedin patients with psychotic disorders. The management of these disorders typically requires long-term treatment with antipsychotic medications, the use of adjunctive pharmacologic treatments, and ongoing psychosocial and supportive interventions to reduce morbidity and mortality. ASHP encourages health professionals to consider the use of second-generation (“atypical” or “novel”) antipsychotics asfirst-line drug treatments for individuals with psychotic disorders. Second-generation antipsychotics share the common pharmacologic action of dual serotonin–dopamine antagonism. While the acquisition costs of these agents are greater than those of older drugs, randomized controlled trials and naturalistic studies have demonstrated that secondgeneration antipsychotics effectively treat thesymptoms of Pharmacologic Characteristics of psychotic disorders while providing a tolerability profile that Antipsychotic Drugs improves treatment adherence and reduces the severity of short- and long-term adverse motor effects. Second-generaThe effectiveness of first-generation antipsychotic agents, tion antipsychotics have also been found to have improved whose primary mechanism of action wasblockade of postprofiles for cognitive impairments in schizophrenia, relative synaptic dopamine type 2 (D2) receptors in the brain, led to to older agents, allowing for opportunities toward psychothe initial hypothesis regarding dopamine’s role in schizosocial rehabilitation. There is also evidence that the use of phrenia. While it is apparent that increased dopamine in the these agents improves...