Initial Antipsychotic Treatment for Psychosis
Start with low-dose atypical antipsychotics—specifically risperidone 2 mg/day or olanzapine 7.5-10 mg/day—and wait 4-6 weeks at adequate dosing before changing treatment, as large initial doses increase side effects without hastening recovery. 1, 2
Pre-Treatment Assessment
Before initiating antipsychotics, rule out physical illnesses that can cause psychosis, including central nervous system infections and traumatic brain injury. 1, 2 Assess for risk of self-harm or aggression to determine if outpatient treatment is safe or if inpatient care is required. 1, 2
First-Line Pharmacological Approach
Medication Selection and Dosing
Use atypical antipsychotics as first-line treatment due to superior tolerability compared to typical agents, even though typical antipsychotics may have equivalent efficacy for positive symptoms. 1, 2
Target doses for most patients:
Avoid exceeding 4-6 mg haloperidol equivalents in first-episode psychosis to minimize extrapyramidal side effects. 1
Critical Dosing Principles
Avoid large initial doses—they do not accelerate recovery but significantly increase side effects and reduce future medication adherence. 2
Any immediate symptom improvement is due to sedation alone; true antipsychotic effects emerge after 1-2 weeks. 2
After initial titration, increase doses only at 14-21 day intervals if response is inadequate, staying within limits of sedation and extrapyramidal symptoms. 1
Consider short-term benzodiazepines as adjuncts to help stabilize the acute situation. 2
Treatment Duration and Assessment
Implement treatment for 4-6 weeks using adequate dosages before determining efficacy. 2 This timeline is critical—switching medications too early (before 4 weeks) or continuing ineffective treatment too long are common pitfalls. 2
If First Treatment Fails
After 4-6 weeks without results or if side effects are unmanageable, switch to a different antipsychotic with a different pharmacodynamic profile. 2
For patients whose first-line treatment was a D2 partial agonist, consider amisulpride, risperidone, paliperidone, or olanzapine as second-line options. 2
If positive symptoms persist after two adequate trials (at least 4 weeks each), reassess the diagnosis and contributing factors before proceeding further. 1, 2
Treatment-Resistant Cases
Consider clozapine only after failure of at least two therapeutic trials of other antipsychotics (at least one being atypical), as it is the only antipsychotic with documented superiority for treatment-refractory schizophrenia. 2 Clozapine is effective in 30-40% of treatment-resistant patients but carries risk of agranulocytosis and requires careful monitoring. 3
Transition to Maintenance Phase
The recuperative phase occurs after 4-12 weeks if acute symptoms are controlled. 2
Maintain antipsychotic medication during this period as additional improvement may occur over 6-12 months. 2
Consider gradual dose reduction to decrease side effects, especially if high doses were needed for acute control. 2
Essential Monitoring
Monitor closely for extrapyramidal side effects, which must be avoided to encourage future medication adherence. 1 High-potency typical antipsychotics are less well tolerated even at low doses compared to atypicals. 1
Family and Psychosocial Integration
Include families in the assessment process and treatment planning from the outset. 1, 2
Provide emotional support and practical advice to families, who are typically in crisis at treatment initiation. 1, 2
Develop supportive crisis plans to facilitate recovery and treatment acceptance. 1, 2
Ensure continuity of care with treating clinicians remaining constant for at least the first 18 months. 2
Common Pitfalls to Avoid
Don't use excessive initial dosing—this leads to unnecessary side effects without therapeutic benefit. 2
Don't switch medications before 4-6 weeks unless side effects are intolerable. 2
Don't neglect side effect monitoring—this is a primary cause of medication non-compliance. 2
Don't abruptly discontinue antipsychotics after acute symptom resolution—maintenance therapy is essential for relapse prevention, as approximately 60% of unmedicated patients relapse within the first year versus less than 20% on prophylactic medication. 4
Don't delay treatment until a crisis develops (self-harm, violence, aggression)—early intervention improves long-term outcomes. 2