ACUTE PHASE TREATMENT. The administration of chlorpromazine or haloperidol will relieve symptoms such as thought disorder, hallucinations and delusions and prevent relapse. They are usually less effective in apathetic, withdrawn patients. However, haloperidol may restore an acutely ill schizophrenic, who was previously withdrawn, or even mute and akinetic, to normal activity and social behaviour. In the acute phase chlorpromazine may be administered by intramuscular injection in a dose of 25 50 mg which can be repeated every 6 8 hours while observing the patient for possible hypotension. In most cases, however, the intramuscular injection is not needed and patients can be treated with an oral dose. Haloperidol may be administered in the acute phase.

MAINTENANCE THERAPY. Long-term treatment in patients with a definite diagnosis of schizophrenia may be necessary after the first episode to prevent the manifest illness from becoming chronic.
The lowest possible dose of antipsychotic drug that will prevent major exacerbations of florid symptoms is used for long-term management. Too rapid a dose reduction should be avoided. Intramuscular depot preparations such as fluphenazine decanoate may be used as an alternative to oral maintenance therapy especially when compliance with oral treatment is unreliable. Exacerbations of illness in patients on maintenance drug therapy can be precipitated by stress.

Withdrawal of maintenance drug treatment requires careful surveillance since it is not possible to predict the course of the disease and the patient may suffer a relapse if treatment is withdrawn inappropriately. Further, the need for continuation of treatment may not be evident on withdrawal of treatment because relapse may be delayed for several weeks.

ADVERSE EFFECTS. They are very common with long-term administration of antipsychotic medicines. Hypotension and interference with temperature regulation, neuroleptic malignant syndrome and bone-marrow depression are the most lifethreatening. Hypotension and interference with temperature regulation are dose-related. They can result in dangerous falls and hypothermia in the elderly and this must be considered before prescribing these drugs for patients over 70 years of age.

Neuroleptic malignant syndrome (hypothermia, fluctuating levels of consciousness, muscular rigidity and autonomic dysfunction with pallor, tachycardia, labile blood pressure, sweating and urinary incontinence) is a rare adverse effect of drugs including haloperidol, chlorpromazine and flupentixol decanoate. It is managed by discontinuation of the antipsychotic medication, attention to fluid and electrolyte balance, and administration of bromocriptine and sometimes dantrolene.

Extrapyramidal symptoms are the most troublesome and are caused most frequently by the piperazine phenothiazines such as fluphenazine, the butyrophenones such as haloperidol and the depot preparations. Although easily recognized, they are not so easy to predict because they depend in part on the dose and patient susceptibility as well as the type of drug. However, there is a general tendency for low-potency drugs to have less extrapyramidal adverse effects, while high-potency drugs such as haloperidol have more extrapyramidal effects but less sedation and anticholinergic (more correctly antimuscarinic) effects. Sedation and anticholinergic effects usually diminish with continued use. Extrapyramidal symptoms consist of parkinsonian-type symptoms including tremor which may occur gradually, dystonia (abnormal face and body movements) which may appear after only a few doses, akathisia (restlessness) and tardive dyskinesia (an orofacial dyskinesia) which usually takes longer to develop. Parkinsonian symptoms are usually reversible on withdrawal of the drug and may be suppressed by anticholinergic (antimuscarinic) drugs but tardive dyskinesia may be irreversible. Tardive dyskinesia is usually associated with long-term treatment and high dosage of neuroleptics, particularly in elderly patients. There is no established treatment for tardive dyskinesias and treatment of all patients on neuroleptic medication must be carefully and regularly reviewed.