Disease: Schizoaffective Disorder

    Schizoaffective disorder facts

    • Schizoaffective disorder is an illness characterized by psychotic symptoms (delusions and hallucinations) and mood problems.
    • There are two types of schizoaffective disorder: bipolar and depressive.
    • There is no specific known cause for schizoaffective disorder.
    • Schizoaffective disorder symptoms and signs include those of schizophrenia in addition to a manic episode and/or a major depressive disorder.
    • The typical treatment for schizoaffective disorder involves the individual taking an antipsychotic drug and possibly a mood stabilizer in addition to psycho-education.

    What is schizoaffective disorder?

    Schizoaffective disorder is an illness with persistent psychotic symptoms, like hallucinations or delusions, occurring together with mood problems of depressive, manic, or mixed episodes. Statistics on how common this disorder is range from 0.2% in the general United States population up to as much as 9% of psychiatrically hospitalized people. Schizoaffective disorder is thought to occur at least as commonly as schizophrenia and less often than bipolar disorder.

    What are the different types of schizoaffective disorder?

    There are two types of schizoaffective disorder: bipolar type and depressive type. The bipolar type of schizoaffective disorder is characterized by the illness including at least one manic episode. The depressive type of this illness involves only major depressive episodes as the mood disorder part of the illness.

    What are causes and risk factors for schizoaffective disorder?

    As with the vast majority of mental disorders, there is not thought to be a specific cause for schizoaffective disorder. Two-thirds of people who develop the illness are women. An immediate family history of schizoaffective disorder, bipolar disorder, or schizophrenia is a risk factor for developing schizoaffective disorder. Developing schizoaffective disorder or another psychotic illness is more than twice as likely in children who suffer significant adversity like bullying, abuse, neglect, or parental death during that time of their lives.

    What are schizoaffective disorder symptoms and signs?

    The symptoms and signs of schizoaffective disorder include those of schizophrenia combined with major depressive disorder and/or a manic episode. Symptoms of schizophrenia may include the following:

    • Hallucinations, like hearing voices, seeing, feeling, tasting, or smelling things that are not there
    • Delusions are ways of thinking with no basis in reality. Types of delusions include paranoid/persecutory, religious, erotic, grandiose, jealous, body (somatic), or mixed (more than one) types
    • Disorganized speech
    • Severely disorganized or catatonic behaviors
    • Negative symptoms, like the decrease or absence of speech (alogia), emotional expression, or movement

    Similar to schizophrenia, schizoaffective disorder is associated with impairments in memory, changing attention, thinking abstractly, and planning. However, people with schizoaffective disorder tend to have better cognitive functioning compared to people with schizophrenia. In terms of brain structure, individuals with schizoaffective disorder tend to have smaller brain volumes compared to the general population, particularly in certain areas of the brain.

    How can schizoaffective disorder be diagnosed?

    To diagnose schizoaffective disorder, one first has to rule out any medical problem that may be the actual cause of the mood and behavioral changes. Once medical causes have been looked for and not found, a mental illness such as schizoaffective disorder could be considered. The diagnosis will best be made by a licensed mental-health professional, like a psychiatrist, who can evaluate the patient and carefully sort through a variety of mental illnesses that might look similarly upon the initial examination. Such illnesses include any other schizophrenia spectrum disorder like schizophrenia, delusional disorder and schizotypal personality disorder, as well as any disorder in which both mood and psychotic symptoms may occur or appear to occur, like borderline personality disorder, dissociative identity disorder or major depression with psychotic features. The physician will examine someone in whom schizoaffective disorder is suspected either in an office or in the emergency department. The physician's role is to ensure that the patient doesn't have any medical problems, including active drug use, since symptoms of those conditions can mimic the symptoms of schizoaffective disorder. The doctor takes the patient's history and performs a physical examination. Laboratory and other tests, sometimes including a computerized tomography (CT) scan of the brain, are performed. Physical findings can relate to the symptoms associated with schizoaffective disorder or to the medications the person may be taking.

    What are criteria for diagnosis of schizoaffective disorder?

    According to the newly released Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), in order to be diagnosed with schizoaffective disorder, an individual must meet the following diagnostic criteria:

    • An uninterrupted period of illness that includes either a major depressive disorder or a manic episode along with at least two active symptoms of schizophrenia (hallucinations, delusions, disorganized speech, severely disorganized or catatonic behaviors, negative symptoms like decreased emotional expression or movement)
    • Delusions or hallucinations occur at least two weeks without major depressive or manic symptoms at some time during the illness.
    • The major mood symptoms occur for most of the duration of the illness.
    • The illness is not the result of a medical condition or the effects of alcohol, other drugs of abuse, or a medication.

    What is the treatment for schizoaffective disorder?

    Treatment for people living with schizoaffective disorder tends to be symptom based rather than distinctly different based on the illness itself. In terms of medication treatment, individuals with the bipolar type of the illness seem to respond best to treatment with an antipsychotic drug combined with a mood-stabilizer drug or treatment with an antipsychotic alone. For people with the depressive type of schizoaffective disorder, combining an antipsychotic medication with an antidepressant tends to work best. Since consistent treatment is important to best outcome, psycho-education of the person with the illness and their loved ones, as well as using long-acting medications can be important parts of their care.

    For people who don't respond to multiple trials of treatment, electroconvulsive therapy may be an option. Treatment for people who suffer from both schizoaffective disorder and a substance-abuse disorder tends to be most effective when both conditions are specifically addressed.

    Antipsychotic medications have been shown to be effective in treating acute psychosis and reducing the risk of future psychotic episodes. The treatment of schizoaffective disorder thus has two main phases: an acute phase, when higher doses of medication might be necessary in order to treat psychotic and severe mood symptoms, followed by a maintenance phase, which could be lifelong. During the maintenance phase, the medication dosage is gradually reduced to the minimum required to prevent further episodes. If symptoms reappear on a lower dosage, a temporary increase in dosage may help prevent a relapse.

    Even with continued treatment, some patients experience relapses. By far, though, the highest relapse rates are seen when medication is discontinued. The large majority of patients experience substantial improvement when treated with antipsychotic agents. Some patients, however, do not respond to medications, and a few may seem not to need them. Since it is difficult to predict which patients will fall into what groups, it is essential to have long-term follow-up, so that the treatment can be adjusted and any problems addressed promptly.

    Medication treatment

    Antipsychotic medications are the cornerstone in the management of schizoaffective disorder. They have been available since the mid-1950s, and although antipsychotics do not cure the illness, they greatly reduce the symptoms and allow the patient to function better, have better quality of life, and enjoy an improved outlook. The choice and dosage of medication is individualized and is best done by a physician who is well trained and experienced in treating severe mental illness.

    The first antipsychotic was discovered by accident and then used for schizophrenia. This was chlorpromazine (Thorazine), which was soon followed by medications such as haloperidol (Haldol), fluphenazine (Prolixin), thiothixene (Navane), trifluoperazine (Stelazine), perphenazine (Trilafon), and thioridazine (Mellaril). These medications have become known as "neuroleptics" because, although effective in treating positive symptoms (for example, acute symptoms such as hallucinations, delusions, thought disorder, loose associations, ambivalence, or emotional lability), they cause side effects, many of which affect the neurologic (nervous) system.

    Since 1989, a new class of antipsychotics (atypical antipsychotics) has been introduced. At clinically effective doses, none (or very few) of these neurological side effects, which often affect the extrapyramidal nerve tracts (which control such things as muscular rigidity, painful spasms, restlessness, or tremors) are observed.

    The first of the new class, clozapine (Clozaril), is not associated with extrapyramidal side effects, but it does produce other side effects, including a possible decrease in the number of white blood cells, so the blood needs to be monitored every week during the first six months of treatment and then every two weeks to catch this side effect early if it occurs.

    Other atypical antipsychotics include risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel and Seroquel-XR), ziprasidone (Geodon), aripiprazole (Abilify), paliperidone (Invega), asenapine (Saphris), iloperidone (Fanapt), and lurasidone (Latuda). The use of these medications has allowed successful treatment and release back to their homes and the community for many people suffering from schizoaffective disorder.

    Although more effective and better tolerated, the use of these agents is also associated with side effects, and current medical practice is developing better ways of understanding these effects, identifying people at risk, and monitoring for the emergence of complications.

    Mood-stabilizer medications like lithium (Lithobid), divalproex (Depakote), carbamazepine (Tegretol, Tegretol XR, Equetro, Carbatrol), and lamotrigine (Lamictal) can be useful in treating active (acute) symptoms of mania as well as preventing return of such symptoms in schizoaffective disorder. These medications may take a bit longer to work compared to the neuroleptic medications, and some (for example, lithium, divalproex, and carbamazepine) require monitoring of medication blood levels, while some can be associated with birth defects when taken by pregnant women.

    Since people with schizoaffective disorder often have depression as part of the illness, medications that address that symptom may be of great benefit as well. Serotonergic medications like fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), and vortioxetine (Brintellix) are often prescribed because of their effectiveness and low incidence of side effects. Other often-prescribed antidepressant medications for treatment of schizoaffective disorder include venlafaxine (Effexor), duloxetine (Cymbalta), desvenlafaxine (Pristiq), and bupropion (Wellbutrin).

    Most of these medications take from several days to four weeks to take effect. Patience is required if the dose needs to be adjusted, the specific medication changed, and another medication added. In order to be able to determine whether an antipsychotic is effective or not, it should be tried for at least six to eight weeks (or even longer with clozapine).

    Nonmedication treatments

    In spite of successful antipsychotic treatment, many patients with schizoaffective disorder have difficulty with motivation, activities of daily living, relationships, and communication skills. Therefore, psychosocial treatments are also important, and many useful treatment approaches have been developed to complement the medications in assisting people suffering from schizoaffective disorder:

    • Individual psychotherapy: This involves regular sessions between just the patient and a therapist focused on past or current problems, thoughts, feelings, or relationships. Thus, via contact with a trained professional, people with schizoaffective disorder become able to understand more about the illness, to learn about themselves, and to better handle the problems of their daily lives. They become better able to differentiate between what is real and, by contrast, what is not and can acquire beneficial problem-solving skills.
    • Rehabilitation: Rehabilitation may include job and vocational counseling, problem solving, social-skills training, and education in money management. Thus, patients learn skills required to live with the illness through successful reintegration into their community following discharge from the hospital and to minimize or eliminate the need for psychiatric hospitalizations.
    • Family education: Research has consistently shown that people with schizoaffective disorder who have involved families have a better prognosis than those who battle the condition alone.
    • Self-help groups: Outside support for family members of those with schizoaffective disorder is necessary and desirable.

    What are complications of schizoaffective disorder?

    There are a number of potential complications of schizoaffective disorder. Obesity, diabetes, and physical inactivity are examples of medical problems that disproportionately affect people with this and other severe mental illnesses. It is estimated that between 46% and 50% of people with a psychotic disorder like schizoaffective disorder have a substance-abuse disorder at some time in their life, most commonly nicotine, followed by alcohol and marijuana abuse. There is research indicating that 34% of people who suffer from either schizoaffective disorder or schizophrenia have attempted suicide. Suicide attempts seems to occur about four years after the first-time psychosis occurs and about seven years after the onset of the first major depressive episode for those who had a history of major depression. Even in the absence of depression, people with a psychotic disorder like schizoaffective disorder or schizophrenia are at higher risk for having suicidal thoughts or attempts.

    What is the prognosis of schizoaffective disorder?

    The prognosis of schizoaffective disorder can be challenging. Some studies indicate that about 47% of people with this illness or schizophrenia can be considered to be in remission after five years, and about one-quarter of individuals have appropriate social functioning for two years or more. The prognosis for people with schizoaffective disorder tends to depend on how well the person was functioning before the illness began, the number of illness episodes the person has, how persistent their psychotic symptoms are, as well as their level of cognitive impairment. Overall, however, individuals who suffer from schizoaffective disorder tend to have psychotic symptoms for a longer time before getting treated and to have a more difficult course compared to those with bipolar disorder. Whether an individual suffers from schizoaffective disorder or schizophrenia, they are more likely to have more frequent, troubling hallucinations and anxiety, as well as more difficulty attending work regularly over time compared to people without those illnesses.

    What are causes and risk factors for schizoaffective disorder?

    As with the vast majority of mental disorders, there is not thought to be a specific cause for schizoaffective disorder. Two-thirds of people who develop the illness are women. An immediate family history of schizoaffective disorder, bipolar disorder, or schizophrenia is a risk factor for developing schizoaffective disorder. Developing schizoaffective disorder or another psychotic illness is more than twice as likely in children who suffer significant adversity like bullying, abuse, neglect, or parental death during that time of their lives.

    What are schizoaffective disorder symptoms and signs?

    The symptoms and signs of schizoaffective disorder include those of schizophrenia combined with major depressive disorder and/or a manic episode. Symptoms of schizophrenia may include the following:

    • Hallucinations, like hearing voices, seeing, feeling, tasting, or smelling things that are not there
    • Delusions are ways of thinking with no basis in reality. Types of delusions include paranoid/persecutory, religious, erotic, grandiose, jealous, body (somatic), or mixed (more than one) types
    • Disorganized speech
    • Severely disorganized or catatonic behaviors
    • Negative symptoms, like the decrease or absence of speech (alogia), emotional expression, or movement

    Similar to schizophrenia, schizoaffective disorder is associated with impairments in memory, changing attention, thinking abstractly, and planning. However, people with schizoaffective disorder tend to have better cognitive functioning compared to people with schizophrenia. In terms of brain structure, individuals with schizoaffective disorder tend to have smaller brain volumes compared to the general population, particularly in certain areas of the brain.

    How can schizoaffective disorder be diagnosed?

    To diagnose schizoaffective disorder, one first has to rule out any medical problem that may be the actual cause of the mood and behavioral changes. Once medical causes have been looked for and not found, a mental illness such as schizoaffective disorder could be considered. The diagnosis will best be made by a licensed mental-health professional, like a psychiatrist, who can evaluate the patient and carefully sort through a variety of mental illnesses that might look similarly upon the initial examination. Such illnesses include any other schizophrenia spectrum disorder like schizophrenia, delusional disorder and schizotypal personality disorder, as well as any disorder in which both mood and psychotic symptoms may occur or appear to occur, like borderline personality disorder, dissociative identity disorder or major depression with psychotic features. The physician will examine someone in whom schizoaffective disorder is suspected either in an office or in the emergency department. The physician's role is to ensure that the patient doesn't have any medical problems, including active drug use, since symptoms of those conditions can mimic the symptoms of schizoaffective disorder. The doctor takes the patient's history and performs a physical examination. Laboratory and other tests, sometimes including a computerized tomography (CT) scan of the brain, are performed. Physical findings can relate to the symptoms associated with schizoaffective disorder or to the medications the person may be taking.

    What are criteria for diagnosis of schizoaffective disorder?

    According to the newly released Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), in order to be diagnosed with schizoaffective disorder, an individual must meet the following diagnostic criteria:

    • An uninterrupted period of illness that includes either a major depressive disorder or a manic episode along with at least two active symptoms of schizophrenia (hallucinations, delusions, disorganized speech, severely disorganized or catatonic behaviors, negative symptoms like decreased emotional expression or movement)
    • Delusions or hallucinations occur at least two weeks without major depressive or manic symptoms at some time during the illness.
    • The major mood symptoms occur for most of the duration of the illness.
    • The illness is not the result of a medical condition or the effects of alcohol, other drugs of abuse, or a medication.

    What is the treatment for schizoaffective disorder?

    Treatment for people living with schizoaffective disorder tends to be symptom based rather than distinctly different based on the illness itself. In terms of medication treatment, individuals with the bipolar type of the illness seem to respond best to treatment with an antipsychotic drug combined with a mood-stabilizer drug or treatment with an antipsychotic alone. For people with the depressive type of schizoaffective disorder, combining an antipsychotic medication with an antidepressant tends to work best. Since consistent treatment is important to best outcome, psycho-education of the person with the illness and their loved ones, as well as using long-acting medications can be important parts of their care.

    For people who don't respond to multiple trials of treatment, electroconvulsive therapy may be an option. Treatment for people who suffer from both schizoaffective disorder and a substance-abuse disorder tends to be most effective when both conditions are specifically addressed.

    Antipsychotic medications have been shown to be effective in treating acute psychosis and reducing the risk of future psychotic episodes. The treatment of schizoaffective disorder thus has two main phases: an acute phase, when higher doses of medication might be necessary in order to treat psychotic and severe mood symptoms, followed by a maintenance phase, which could be lifelong. During the maintenance phase, the medication dosage is gradually reduced to the minimum required to prevent further episodes. If symptoms reappear on a lower dosage, a temporary increase in dosage may help prevent a relapse.

    Even with continued treatment, some patients experience relapses. By far, though, the highest relapse rates are seen when medication is discontinued. The large majority of patients experience substantial improvement when treated with antipsychotic agents. Some patients, however, do not respond to medications, and a few may seem not to need them. Since it is difficult to predict which patients will fall into what groups, it is essential to have long-term follow-up, so that the treatment can be adjusted and any problems addressed promptly.

    Medication treatment

    Antipsychotic medications are the cornerstone in the management of schizoaffective disorder. They have been available since the mid-1950s, and although antipsychotics do not cure the illness, they greatly reduce the symptoms and allow the patient to function better, have better quality of life, and enjoy an improved outlook. The choice and dosage of medication is individualized and is best done by a physician who is well trained and experienced in treating severe mental illness.

    The first antipsychotic was discovered by accident and then used for schizophrenia. This was chlorpromazine (Thorazine), which was soon followed by medications such as haloperidol (Haldol), fluphenazine (Prolixin), thiothixene (Navane), trifluoperazine (Stelazine), perphenazine (Trilafon), and thioridazine (Mellaril). These medications have become known as "neuroleptics" because, although effective in treating positive symptoms (for example, acute symptoms such as hallucinations, delusions, thought disorder, loose associations, ambivalence, or emotional lability), they cause side effects, many of which affect the neurologic (nervous) system.

    Since 1989, a new class of antipsychotics (atypical antipsychotics) has been introduced. At clinically effective doses, none (or very few) of these neurological side effects, which often affect the extrapyramidal nerve tracts (which control such things as muscular rigidity, painful spasms, restlessness, or tremors) are observed.

    The first of the new class, clozapine (Clozaril), is not associated with extrapyramidal side effects, but it does produce other side effects, including a possible decrease in the number of white blood cells, so the blood needs to be monitored every week during the first six months of treatment and then every two weeks to catch this side effect early if it occurs.

    Other atypical antipsychotics include risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel and Seroquel-XR), ziprasidone (Geodon), aripiprazole (Abilify), paliperidone (Invega), asenapine (Saphris), iloperidone (Fanapt), and lurasidone (Latuda). The use of these medications has allowed successful treatment and release back to their homes and the community for many people suffering from schizoaffective disorder.

    Although more effective and better tolerated, the use of these agents is also associated with side effects, and current medical practice is developing better ways of understanding these effects, identifying people at risk, and monitoring for the emergence of complications.

    Mood-stabilizer medications like lithium (Lithobid), divalproex (Depakote), carbamazepine (Tegretol, Tegretol XR, Equetro, Carbatrol), and lamotrigine (Lamictal) can be useful in treating active (acute) symptoms of mania as well as preventing return of such symptoms in schizoaffective disorder. These medications may take a bit longer to work compared to the neuroleptic medications, and some (for example, lithium, divalproex, and carbamazepine) require monitoring of medication blood levels, while some can be associated with birth defects when taken by pregnant women.

    Since people with schizoaffective disorder often have depression as part of the illness, medications that address that symptom may be of great benefit as well. Serotonergic medications like fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), and vortioxetine (Brintellix) are often prescribed because of their effectiveness and low incidence of side effects. Other often-prescribed antidepressant medications for treatment of schizoaffective disorder include venlafaxine (Effexor), duloxetine (Cymbalta), desvenlafaxine (Pristiq), and bupropion (Wellbutrin).

    Most of these medications take from several days to four weeks to take effect. Patience is required if the dose needs to be adjusted, the specific medication changed, and another medication added. In order to be able to determine whether an antipsychotic is effective or not, it should be tried for at least six to eight weeks (or even longer with clozapine).

    Nonmedication treatments

    In spite of successful antipsychotic treatment, many patients with schizoaffective disorder have difficulty with motivation, activities of daily living, relationships, and communication skills. Therefore, psychosocial treatments are also important, and many useful treatment approaches have been developed to complement the medications in assisting people suffering from schizoaffective disorder:

    • Individual psychotherapy: This involves regular sessions between just the patient and a therapist focused on past or current problems, thoughts, feelings, or relationships. Thus, via contact with a trained professional, people with schizoaffective disorder become able to understand more about the illness, to learn about themselves, and to better handle the problems of their daily lives. They become better able to differentiate between what is real and, by contrast, what is not and can acquire beneficial problem-solving skills.
    • Rehabilitation: Rehabilitation may include job and vocational counseling, problem solving, social-skills training, and education in money management. Thus, patients learn skills required to live with the illness through successful reintegration into their community following discharge from the hospital and to minimize or eliminate the need for psychiatric hospitalizations.
    • Family education: Research has consistently shown that people with schizoaffective disorder who have involved families have a better prognosis than those who battle the condition alone.
    • Self-help groups: Outside support for family members of those with schizoaffective disorder is necessary and desirable.

    What are complications of schizoaffective disorder?

    There are a number of potential complications of schizoaffective disorder. Obesity, diabetes, and physical inactivity are examples of medical problems that disproportionately affect people with this and other severe mental illnesses. It is estimated that between 46% and 50% of people with a psychotic disorder like schizoaffective disorder have a substance-abuse disorder at some time in their life, most commonly nicotine, followed by alcohol and marijuana abuse. There is research indicating that 34% of people who suffer from either schizoaffective disorder or schizophrenia have attempted suicide. Suicide attempts seems to occur about four years after the first-time psychosis occurs and about seven years after the onset of the first major depressive episode for those who had a history of major depression. Even in the absence of depression, people with a psychotic disorder like schizoaffective disorder or schizophrenia are at higher risk for having suicidal thoughts or attempts.

    What is the prognosis of schizoaffective disorder?

    The prognosis of schizoaffective disorder can be challenging. Some studies indicate that about 47% of people with this illness or schizophrenia can be considered to be in remission after five years, and about one-quarter of individuals have appropriate social functioning for two years or more. The prognosis for people with schizoaffective disorder tends to depend on how well the person was functioning before the illness began, the number of illness episodes the person has, how persistent their psychotic symptoms are, as well as their level of cognitive impairment. Overall, however, individuals who suffer from schizoaffective disorder tend to have psychotic symptoms for a longer time before getting treated and to have a more difficult course compared to those with bipolar disorder. Whether an individual suffers from schizoaffective disorder or schizophrenia, they are more likely to have more frequent, troubling hallucinations and anxiety, as well as more difficulty attending work regularly over time compared to people without those illnesses.

    Source: http://www.rxlist.com

    Treatment for people living with schizoaffective disorder tends to be symptom based rather than distinctly different based on the illness itself. In terms of medication treatment, individuals with the bipolar type of the illness seem to respond best to treatment with an antipsychotic drug combined with a mood-stabilizer drug or treatment with an antipsychotic alone. For people with the depressive type of schizoaffective disorder, combining an antipsychotic medication with an antidepressant tends to work best. Since consistent treatment is important to best outcome, psycho-education of the person with the illness and their loved ones, as well as using long-acting medications can be important parts of their care.

    For people who don't respond to multiple trials of treatment, electroconvulsive therapy may be an option. Treatment for people who suffer from both schizoaffective disorder and a substance-abuse disorder tends to be most effective when both conditions are specifically addressed.

    Antipsychotic medications have been shown to be effective in treating acute psychosis and reducing the risk of future psychotic episodes. The treatment of schizoaffective disorder thus has two main phases: an acute phase, when higher doses of medication might be necessary in order to treat psychotic and severe mood symptoms, followed by a maintenance phase, which could be lifelong. During the maintenance phase, the medication dosage is gradually reduced to the minimum required to prevent further episodes. If symptoms reappear on a lower dosage, a temporary increase in dosage may help prevent a relapse.

    Even with continued treatment, some patients experience relapses. By far, though, the highest relapse rates are seen when medication is discontinued. The large majority of patients experience substantial improvement when treated with antipsychotic agents. Some patients, however, do not respond to medications, and a few may seem not to need them. Since it is difficult to predict which patients will fall into what groups, it is essential to have long-term follow-up, so that the treatment can be adjusted and any problems addressed promptly.

    Source: http://www.rxlist.com

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