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CAREMARK
Clinical Update
Pharmaceutical Issues and Prescribing Trends for Today’s Professional Working in Healthcare
JULY 2003
Schizophrenia
Background
About two million Americans suffer from
schizophrenia, a disease that causes hallucinations,
delusions, and paranoia. It is estimated to cost
about $65 billion a year in direct treatment, societal,
and family costs. If left untreated, persons with
schizophrenia can have poorer outcomes, leading to
greater healthcare costs.1 This illness, which affects
approximately 1% of the adult population, typically
develops in the late teens or early twenties.
Individuals with schizophrenia are usually in lower
socioeconomic classes as they often experience
markedly impaired work function.2,3
Causes
The exact cause of schizophrenia is unknown,
however it tends to be hereditary. An identical twin
of a person with schizophrenia has a 40% to 50%
chance of developing the disease, and a child whose
parent has schizophrenia has a 10% chance,
compared to the 1% risk seen in the general
population. There has been evidence linking
schizophrenia to an imbalance of neurotransmitters
(chemical messengers) in the brain, such as
dopamine and glutamine.4 Others believe that
difficulties prior to birth (such as starvation while in
the mother’s uterus or viral infections), complications
around the time of birth, and various nonspecific
conditions that cause stress,
are involved in the developAuthors:
ment of schizophrenia.
Audrey Moyna,
Abnormalities in brain strucPharmD, RPh
ture have also been
Chris Baek, PharmD,
observed in many
MAEd
individuals with
Editorial Contact:
schizophrenia. Studies are
Dana Udovich,
ongoing to determine the
PharmD
exact cause(s) of this
publications@
disorder.5
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Symptoms
Schizophrenia is a chronic
and disabling mental illness
characterized by a wide array of unusual internal
experiences, socially inappropriate behavior, and
reduced participation in normal social and
occupational activities.4 People with schizophrenia
may have altered perceptions of reality that are
strikingly different from those around them. They
often suffer terrifying symptoms such as imaginary
voices and beliefs that other people are reading their
minds, controlling their thoughts, or plotting to harm
them. Clinical symptoms of the illness are generally
categorized as positive symptoms or negative
symptoms. Positive symptoms include delusions,
hallucinations, agitation, disorganized speech or
behavior, and paranoia. Negative symptoms consist
of inability to show emotion, emotional or social
withdrawal, and indifference. Less obvious
symptoms, such as social isolation or withdrawal, or
unusual speech, thinking, or behavior may also be
present.4
Outcomes
Individuals with schizophrenia can have poor social
and occupational outcomes, and often have difficulty
maintaining relationships and holding down steady
jobs.5 However, their quality of life can improve if
they are compliant and responsive to medications.4
Treatment
Typical Antipsychotics
The first drugs developed for schizophrenia, now
called “typical antipsychotics”, changed the
treatment of this disease in the 1950s. These
medications have been effective in reducing positive
symptoms associated with schizophrenia, but have
limited effect on the negative symptoms. Typical
antipsychotics also tend to cause many adverse
effects, including sedation, involuntary movements,
extrapyramidal side effects (e.g., tremor, slurred
CAREMARK
Clinical Update
JULY 2003
speech, or anxiety), increased prolactin levels (a
hormone made by the pituitary gland), and weight
gain.4
Atypical Antipsychotics
During the last decade, newer antipsychotic drugs
(i.e., “atypical antipsychotics”) with different
mechanisms of action, have been widely used in the
treatment of schizophrenia. Examples include
Risperdal® (risperidone), Seroquel® (quetiapine), and
Zyprexa® (olanzapine). These drugs may also be used
in other disorders, such as bipolar disorder, mania, or
psychotic symptoms. Atypical antipsychotics provide
effective treatment of both positive and negative
symptoms without the side effects associated with
the typical antipsychotics. A major advantage of
these newer products is the reduction of
extrapyramidal side effects. However, these atypical
antipsychotics can be associated with different side
effects, including: weight gain, changes in the way
blood sugar is processed, increased blood cholesterol, a decrease of certain white blood cells
(infection fighting cells), inflammation and disease of
the heart muscle, increased prolactin levels, and
abnormal rhythms of the heart. Increased prolactin
may interfere with ovulation in women, decreased
libido in men, and decreased fertility. Weight gain is
an important consideration among doctors because
it can increase the risk of diabetes or high blood
sugar, heart attack, stroke, and may cause some
appearance-conscious individuals to stop their
medication. The goal of newer medications is to
improve efficacy while decreasing the side effects of
these medications.4
Benefits and Risks Associated with
Antipsychotic Use
Antipsychotic medications can reduce the intensity
and frequency of psychotic relapses (return of signs
and symptoms), enabling 60% to 70% of individuals
to live within the normal community.2,6 However, as
mentioned previously, they can cause side effects,
such as weight gain, seizures, and certain blood
disorders. They can also predispose individuals to
certain complications, such as heart disease and
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diabetes. Despite the risks associated with
antipsychotic use, these medications have enabled
many people with schizophrenia to work and lead
more productive lives.4
Clinical Initiatives
Antipsychotic agents are unique drugs used in the
treatment of quite a disabling condition. One
Caremark clinical program, such as SecureCare, helps
to ensure that antipsychotic drugs are appropriately
dispensed and utilized. This is accomplished through
monitoring of refills, drug-drug interactions, and
verification of high-dose prescriptions. The
Pharmaceutical Services division also sends
information to physicians concerning the latest
clinical findings on new antipsychotics. These
initiatives are an important process in the overall
management of participants living with this disorder,
so that they lead more productive, self-sufficient
lives.
References
1. The Schizophrenia Homepage. Available at:
http://www.schizophrenia.com. Accessed June 5, 2003.
2. National Institute of Mental Health. Schizophrenia Research.
Available at: http://www.nimh.nih.gov. Accessed
January 15, 2003.
3. Schultz SK, Andreasen NC. Schizophrenia. Lancet. 1999;
353:1425-30.
4. Meltzer HY, Fatemi SH. Schizophrenia. In: Current
diagnosis & treatment in psychiatry. Ebert MH, Loosen PT,
Nurcombe B, eds. New York: Lange Medical Books/McGraw-Hill;
2000:260-77.
5. National Institute of Mental Health. Schizophrenia. Available at:
http://www.nimh.nih.gov. Accessed January 15, 2003.
6. Williamson JS, Wyandt CM. Treating schizophrenia. New
strategies. Drug Topics. 2000; 21(144):64-84.
The Caremark Clinical Update is provided as reference material and is
based in part on information derived from third parties. Caremark
does not assume any liability or responsibility for the accuracy or
completeness of any third party material footnoted in this piece.