Antipsychotics and crime

Definition: Group of drugs used to treat psychotic disorders such as schizophrenia and mania.

Significance: Antipsychotic drugs have the ability to reduce psychotic symptoms without necessarily producing drowsiness and sedation. Forensic psychiatrists as well as law-enforcement personnel are familiar with antipsychotics because many criminals with mental illnesses use such drugs.

Antipsychotic drugs, also known as neuroleptic drugs or neuroleptics, were first discovered in the late 1940’s by Henri Laborit, a French surgeon. Laborit found that when phenothiazines were used in conjunction with surgical anesthesia, the patients became less concerned about their surgery, and he thought that these drugs might be useful for reducing the emotionality of psychiatric patients. Since that time, the use of antipsychotics has become common in psychiatry. Initially, these drugs were called tranquilizers, but as that term seemed to imply sedation, its use was dropped.

All antipsychotic drugs tend to block dopamine receptors in the mesolimbic pathway of the brain; this accounts for their antipsychotic action. The drugs range in potency based on their ability to bind with dopamine receptors. High-potency antipsychotics such as haloperidol require lower dosage (usually a few milligrams) than do low-potency antipsychotics such as chlorpromazine (usually several hundred milligrams). Persons who are prescribed antipsychotics need to be monitored for regular intake, as compliance with drug therapy is an important aspect of treatment for psychotic disorders.

Typical Antipsychotics

Antipsychotics are classified as typical or atypical. Typical, or conventional, antipsychotics (and some of the trade names under which they are sold) include chlorpromazine (Thorazine), thioridazine (Mellaril), mesoridazine (Serentil), loxapine (Loxitane), perphenazine (Trilafon), molindone (Moban), thiothixene (Navane), trifluoperazine (Stelazine), fluphenazine (Prolixin), haloperidol (Haldol), and pimozide (Orap). These kinds of drugs were the first antipsychotics to be developed. The efficacy of typical and atypical antipsychotics is comparable, but typical antipsychotics have the drawback of possibly severe side effects. The main side effects of typical antipsychotics are known as extrapyramidal symptoms—a name arising out of the part of the brain that is stimulated by the drugs. Akathisia, a syndrome involving a subjective desire to be in constant motion and an inability to sit still or stand still, with consequent pacing, is the most common side effect.

Side effects of typical antipsychotics may also take the form of facial tics. Sometimes Parkinson’s disease (which is marked by tremors of the hands while they are at rest, muscular rigidity, a masklike face, and a shuffling walk) may be precipitated by antipsychotic drugs. Tardive dyskinesia—the term means “late-appearing abnormal movements”—is among the most serious complications of antipsychotic treatment. It involves repetitive sucking and smacking movements of the lips, thrusting in and out of the tongue, and movements of the arms, toes, or fingers.

Typical antipsychotics can also have several anticholinergic side effects, such as dry mouth, blurred near vision, urinary retention, delayed emptying of the stomach, esophageal reflux, and precipitation of glaucoma. Often these drugs have metabolic and endocrine effects as well, such as weight gain, high blood glucose, temperature irregularities, and menstrual irregularities. Some allergic reactions may also occur, such as jaundice or skin rashes. Rarely, agranulocytosis, or low white blood cell count, can develop in the early stages of treatment.

Atypical Antipsychotics

Atypical antipsychotic medications (and some of the trade names under which they are sold) include clozapine (Clozaril, Fazaclo), risperidone (Risperdal), olanzepine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), and aripiprazole (Abilify). These drugs have an advantage over typical antipsychotics in that they have no extrapyramidal side effects (such as Parkinsonism, akathisia, and tardive dyskinesia). Atypical antipsychotics are at least as effective as conventional or typical agents in inducing positive symptoms, and they also help to improve cognition and enhance mood.

Atypical antipsychotics are not completely free of side effects, however, and the side effects differ from drug to drug. Risperidone, for example, causes an increase in prolactin levels—a hormone that can lead to breast enlargement, production of breast milk, and irregular menses. In high doses, this drug can also cause extrapyramidal side effects. Olanzepine can cause weight gain and may produce modest prolactin elevation. Ziprasidone can cause drowsiness, dry mouth, runny nose, symptoms of high blood sugar, and allergic reactions. Quetiapine can cause drowsiness, dizziness, agitation, pain, and weakness. Clozapine can cause weight gain and sedation.

Bibliography

De Oliveira, Irismar R., and M. F. Juruena. “Treatment of Psychosis: Thirty Years of Progress.” Journal of Clinical Pharmacy and Therapeutics 31, no. 6 (2006): 523-534. Discusses the evolution of antipsychotics, particularly the general replacement of typical antipsychotics with atypical antipsychotics, largely because the latter lack extrapyramidal side effects.

Parker, John, Jana De Villiers, and Samantha Churchward. “High-Dose Antipsychotic Drug Use in a Forensic Setting.” Journal of Forensic Psychiatry and Psychology 13, no. 2 (2002): 407-415. Presents the results of a study of the application of antipsychotics in a forensic psychiatric setting.

Pinals, D. A., and P. F. Buckley. “Novel Antipsychotic Agents and Their Implications for Forensic Psychiatry.” Journal of the American Academy of Psychiatry and the Law 27, no. 1 (1999): 7-22. Review of the literature on the clinical efficacy and mechanisms of action of atypical antipsychotics focuses on their use in forensic psychiatry. Concludes that use of these medications may reduce the risk of civil litigation.

Scherk, Harald, and Peter Falkai. “Effects of Antipsychotics on Brain Structure.” Current Opinion in Psychiatry 19, no. 2 (2006): 145-150. Discusses the different effects of typical and atypical antipsychotics on brain structure and presents evidence that atypical antipsychotics might ameliorate structural changes caused by the disease process underlying schizophrenia.

Silverstone, Trevor, and Paul Turner. Drug Treatment in Psychiatry. 5th ed. New York: Routledge, 1995. Examines both general principles of psychiatric drug treatment and specific clinical applications of antipsychotic drugs.

Sinacola, Richard S., and Timothy Peters-Strickland. Basic Psychopharmacology for Counselors and Psychotherapists. Boston: Pearson, 2006. Basic text includes a chapter devoted to the treatment of psychotic disorders and the use of antipsychotics.

Stahl, Stephen M. Essential Psychopharmacology: The Prescriber’s Guide. Rev ed. New York: Cambridge University Press, 2006. Guidebook for practitioners covers the most important and common drugs used for mood stabilization and treatment of psychosis. Includes information on the advantages and disadvantages of each drug, presented in easy-to-read and user-friendly style.