What are the criteria for selecting an antipsychotic medication in a patient with psychosis?

From the Guidelines

The selection of an antipsychotic medication in a patient with psychosis should be based on a comprehensive assessment of the patient's symptoms, medical history, and potential side effect profile, with a focus on reducing morbidity, mortality, and improving quality of life, as recommended by the American Psychiatric Association practice guideline for the treatment of patients with schizophrenia 1. When choosing an antipsychotic medication, it is essential to consider the patient's specific symptom profile, medical comorbidities, and potential side effects.

• First-line options typically include second-generation (atypical) antipsychotics such as risperidone, olanzapine, quetiapine, or aripiprazole, which generally have fewer extrapyramidal side effects than first-generation antipsychotics like haloperidol.
• The initial assessment of a patient with a possible psychotic disorder should include a review of psychiatric symptoms and trauma history, an assessment of tobacco use and other substance use, a psychiatric treatment history, an assessment of physical health, and an assessment of psychosocial and cultural factors, as outlined in the APA's Practice Guidelines for the Psychiatric Evaluation of Adults 1.
• The APA recommends that patients with schizophrenia have a documented, comprehensive, and person-centered treatment plan that includes evidence-based nonpharmacological and pharmacological treatments 1.
• Medical comorbidities are crucial in selection: avoid olanzapine in patients with metabolic syndrome, quetiapine in those with cardiovascular disease, and consider ziprasidone or aripiprazole for patients with weight concerns.
• Monitor for side effects including metabolic changes (weight gain, glucose dysregulation), movement disorders (akathisia, tardive dyskinesia), QTc prolongation, and sedation.
• Start with low doses and titrate gradually while assessing response.
• Clozapine should be considered for treatment-resistant psychosis after failed trials of at least two other antipsychotics, as recommended by the APA 1. The mechanism of action for most antipsychotics involves dopamine D2 receptor antagonism, with atypicals also affecting serotonin receptors, which helps explain their efficacy and different side effect profiles. It is also important to consider the patient's preferences and values when selecting an antipsychotic medication, as well as their ability to adhere to the treatment plan. In terms of specific medications, the APA recommends that patients with schizophrenia be treated with an antipsychotic medication and monitored for effectiveness and side effects 1. The choice of antipsychotic medication should be individualized based on the patient's specific needs and circumstances, and should be guided by the latest evidence-based guidelines and research, such as the American Psychiatric Association practice guideline for the treatment of patients with schizophrenia 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Criteria for Selecting an Antipsychotic Medication

The selection of an antipsychotic medication in a patient with psychosis depends on several factors, including the patient's diagnosis, age, medical history, and previous response to treatment. The following are some key considerations:

• Diagnosis: The choice of antipsychotic medication may vary depending on the patient's diagnosis. For example, olanzapine, risperidone, and aripiprazole may be preferred for the treatment of first-episode psychosis 2, while haloperidol, olanzapine, and risperidone may be more effective for the acute treatment of psychosis in hospitalized patients with schizophrenia, schizoaffective disorder, or schizophreniform disorder 3.
• Side effect profile: The side effect profile of the antipsychotic medication is an important consideration. For example, olanzapine is associated with a higher risk of weight gain and metabolic side effects, while risperidone is associated with a higher risk of extrapyramidal symptoms 4.
• Previous response to treatment: The patient's previous response to treatment is also an important consideration. For example, if a patient has previously responded well to a particular antipsychotic medication, it may be preferred for future treatment 5.
• Medical history: The patient's medical history is also an important consideration. For example, patients with diabetes, dyslipidemia, or obesity may require antipsychotic medications with a lower risk of metabolic side effects, such as aripiprazole or ziprasidone 5.

Antipsychotic Medication Options

The following are some common antipsychotic medication options:

• Olanzapine: Olanzapine is a second-generation antipsychotic medication that is effective for the treatment of schizophrenia and other psychotic disorders. It is associated with a higher risk of weight gain and metabolic side effects, but may be preferred for patients with a history of treatment-resistant psychosis 4.
• Risperidone: Risperidone is a second-generation antipsychotic medication that is effective for the treatment of schizophrenia and other psychotic disorders. It is associated with a higher risk of extrapyramidal symptoms, but may be preferred for patients with a history of anxiety or depression 4.
• Aripiprazole: Aripiprazole is a second-generation antipsychotic medication that is effective for the treatment of schizophrenia and other psychotic disorders. It is associated with a lower risk of metabolic side effects and may be preferred for patients with diabetes, dyslipidemia, or obesity 5.
• Quetiapine: Quetiapine is a second-generation antipsychotic medication that is effective for the treatment of schizophrenia and other psychotic disorders. It is associated with a higher risk of sedation and weight gain, but may be preferred for patients with a history of anxiety or depression 5.
• Ziprasidone: Ziprasidone is a second-generation antipsychotic medication that is effective for the treatment of schizophrenia and other psychotic disorders. It is associated with a lower risk of metabolic side effects and may be preferred for patients with diabetes, dyslipidemia, or obesity 5.

Treatment Guidelines

The following are some general treatment guidelines for antipsychotic medications:

• First-episode psychosis: Olanzapine, risperidone, and aripiprazole may be preferred for the treatment of first-episode psychosis due to their effectiveness and relatively favorable side effect profiles 2.
• Acute psychosis: Haloperidol, olanzapine, and risperidone may be more effective for the acute treatment of psychosis in hospitalized patients with schizophrenia, schizoaffective disorder, or schizophreniform disorder 3.
• Maintenance treatment: The choice of antipsychotic medication for maintenance treatment should be based on the patient's previous response to treatment and side effect profile. Olanzapine, risperidone, and aripiprazole may be preferred for maintenance treatment due to their effectiveness and relatively favorable side effect profiles 5, 2.