Other drugs

Many patients with pronounced mood instability or depression - or more commonly flatness - of mood can be prescribed mood stabilizers or antidepressants. If the question arises, there is often a strong case for at least trying the effect of such medications; response is unpredictable. Sometimes there is an improvement. Even if there is no benefit, at least the practitioner will have tried, and will therefore have been seen to have listened to the patient, his family, and/or his care coordinator. This cannot but be helpful to the building up of a therapeutic relationship.

Clozapine NICE is very positive about the use of this drug in treatment-resistant schizophrenia: 'In individuals with evidence of treatment-resistant schizophrenia (TRS), clozapine should be introduced at the earliest opportunity. TRS is suggested by a lack of satisfactory clinical improvement despite the sequential use of the recommended doses for 6 to 8 weeks of at least two antipsychotics, at least one of which should be an atypical' (http://www.nice.org.uk/page. aspx?o=TA043guidance). The disadvantages of clozapine include the fact that it can cause bone marrow suppression, and therefore frequent monitoring of blood tests is required; even with careful monitoring, occasional deaths occur. It can only be given by mouth, and often causes hypersalivation.

However, most practising clinicians would agree that these disadvantages are outweighed by the advantages, which are that it can produce improvements when other medications have failed to do so. It is very rewarding for all concerned when a patient who has been severely unwell in the hospital experiences symptomatic and functional improvement after clozapine treatment and can be discharged. The effect can take weeks or months to build up, and residual symptoms and impairments may continue to some extent. Nevertheless, this drug can offer dramatic improvements in symptoms and quality of life.

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