Focal neuroleptization: an approach to optimal dosing for initial and continuing therapy

Concerns about the cumulative effects of long-term neuroleptic therapy have stimulated interest in approaches to assure the lowest possible effective medication level. The examination of present strategies to assure that they are consistent with overall treatment goals is one approach that can significantly contribute to lower-dose therapy. To this end the technique of rapid neuroleptization, which originated in the 1950s, has been assessed and redefined as focal neuroleptization, a term which directs attention to the integral relationship between acute and chronic therapy. Dosing practices that have become associated with rapid neuroleptization are less likely to occur with focal neuroleptization: the use of unnecessarily high doses during acute therapy and the failure to reduce dosages to appropriate levels for maintenance. Studies comparing high dose (above 10 to 20 mg/day of haloperidol or the equivalent of other high potency neuroleptics) with low dose therapy show that there are no significant differences in the completeness or speed of symptom remission. High doses during acute therapy make low dose maintenance more difficult to achieve. In light of these findings, physicians are encouraged to re-evaluate their approach to high dose therapy for rapid neuroleptization. The objective is to achieve the lowest possible effective dose of medication during both acute and maintenance phases of therapy. The term focal neuroleptization encompasses the key elements of neuroleptic therapy: rapid reduction of target symptoms as the end point of initial therapy, focus on individualized treatment, and low dose maintenance therapy.