From the Guidelines
If aripiprazole is unsuccessful as a first treatment for first episode psychosis, the next step would typically be to try another second-generation (atypical) antipsychotic medication such as olanzapine, risperidone, quetiapine, or paliperidone, as recommended by the American Psychiatric Association practice guideline for the treatment of patients with schizophrenia 1. The choice of the next antipsychotic should be individualized based on the patient's specific symptoms, side effect profile, and preferences.
- Generally, a trial of 4-6 weeks at an adequate dose is recommended before determining efficacy.
- If the second antipsychotic is also ineffective, options include trying a third antipsychotic from a different class, considering clozapine (particularly after two failed trials), or augmentation strategies.
- Throughout this process, comprehensive psychosocial interventions should continue, including cognitive behavioral therapy, family support, and psychoeducation, as suggested by the American Psychiatric Association practice guideline for the treatment of patients with schizophrenia 1. The rationale for switching medications relates to different receptor binding profiles among antipsychotics, as individuals may respond differently based on their unique neurochemical imbalances.
- Treatment resistance in first-episode psychosis occurs in approximately 20-30% of patients, making sequential medication trials a common and necessary approach.
- Additionally, antipsychotic polypharmacy may be considered in some cases, although a clozapine trial should always be seriously considered before switching to antipsychotic polypharmacy, as clozapine has been shown to be the most effective treatment for treatment-resistant patients 2.
From the Research
Next Steps After Aripiprazole Treatment Failure
If aripiprazole is used as a first treatment for the first episode of psychosis and it's unsuccessful, the next steps may involve:
- Switching to a different antipsychotic medication, as suggested by studies 3, 4 that compared the effectiveness of various antipsychotics in treating first-episode psychosis.
- Considering the side effect profiles and efficacy of different antipsychotics, such as olanzapine, risperidone, haloperidol, ziprasidone, and quetiapine, as reported in studies 3, 4.
- Taking into account the patient's individual characteristics, such as age, symptoms, and medical history, to guide the selection of the next treatment, as implied by study 5.
- Monitoring the patient's response to the new treatment and adjusting the medication regimen as needed to achieve optimal outcomes.
Factors Influencing Treatment Selection
When selecting a new treatment after aripiprazole failure, several factors should be considered, including:
- The patient's symptom profile and severity of psychosis, as discussed in studies 6, 7.
- The potential side effects of different antipsychotics, such as weight gain, sedation, and extrapyramidal symptoms, as reported in studies 3, 4.
- The patient's adherence to the medication regimen and potential barriers to adherence, as explored in study 5.
- The availability of support services and resources to help the patient manage their condition and adhere to treatment.