medication as soon as it is feasible. It may be appropriate to delay
pharmacologic treatment for patients who require more extensive
diagnostic evaluation or who refuse medications or if psychosis
is caused by substance use or acute stress reactions.
Discuss risks and benefits of the medication with the
patient before initiating treatment, if feasible, and identify target
symptoms (e.g., anxiety, poor sleep, hallucinations, and delusions)
and acute side effects (e.g., orthostatic hypotension, dizziness,
dystonic reactions, insomnia, and sedation).
Assess baseline levels of signs, symptoms, and laboratory
values relevant to monitoring effects of antipsychotic therapy.
signs (pulse, blood pressure, temperature).
Measure weight, height, and body mass index
(BMI), which can be calculated with the formula weight in kilograms/(height
in meters)2 or the formula 703 x weight
in pounds/(height in inches)2 or
with a BMI table: http://win.niddk.nih.gov/statistics/index.htm#table
Assess for extrapyramidal signs and abnormal
Screen for diabetes risk factors and measure
fasting blood glucose.
Screen for symptoms of hyperprolactinemia.
Obtain lipid panel.
Obtain ECG and serum potassium measurement
before treatment with thioridazine, mesoridazine, or pimozide; obtain
ECG before treatment with ziprasidone in the presence of cardiac
Conduct ocular examination, including slit-lamp
examination, when beginning antipsychotics associated with increased
risk of cataracts.
Screen for changes in vision.
Consider a pregnancy test for women with
Minimize acute side effects (e.g., dystonia) that can
influence willingness to accept and continue pharmacologic treatment.
Initiate rapid emergency treatments when an acutely
psychotic patient is exhibiting aggressive behaviors toward self
Try talking to
the patient in an attempt to calm him or her.
Restraining the patient should be done only
by a team trained in safe restraint procedures.
Use short-acting parenteral formulations
of first- or second-generation antipsychotic agents with or without
Alternatively, use rapidly dissolving oral
formulations of second-generation agents (e.g., olanzapine, risperidone)
or oral concentrate formulations (e.g., risperidone, haloperidol).
See Tables 1 and 2 and Figure 1 for guidance in determining somatic treatment.
Select medication depending on the following factors:
of symptom response
Past experience of side effects
Side effect profile of prospective medications
(see Table 3)
Patient's preferences for a particular
medication, including route of administration
Available formulations of medications (e.g.,
tablet, rapidly dissolving tablet, oral concentrate, short- and
Consider second-generation antipsychotics
as first-line medications because of the decreased risk for extrapyramidal
side effects and tardive dyskinesia.
who have had prior treatment success or who prefer first-generation
agents, these medications are useful and for specific patients may
be the first choice.
With the possible exception of clozapine
for patients with treatment-resistant symptoms, antipsychotics generally
have similar efficacy in treating positive symptoms.
Second-generation antipsychotics may have
superior efficacy in treating global psychopathology and cognitive,
negative, and mood symptoms.
Consider long-acting injectable antipsychotic medication
for patients with recurrent relapses related to partial or full
nonadherence. The oral form of the same medication (e.g., fluphenazine, haloperidol,
and risperidone) is the logical choice for initial treatment.
Titrate as quickly as tolerated to the
target therapeutic dose (sedation, orthostatic hypotension, and tachycardia
are generally the side effects that limit the rate of increase),
and monitor clinical status for at least 2 to 4 weeks.
The optimal dose
of first-generation antipsychotics is, for most patients, at the "extrapyramidal symptom
(EPS) threshold," or the dose at which minimal rigidity
is detectable on physical examination.
For second-generation antipsychotics, target
dose usually falls within the therapeutic dose range specified by
the manufacturer and in the package labeling approved by the U.S.
Food and Drug Administration.
If the patient is not improving, consider whether the
lack of response can be explained by medication nonadherence, rapid
medication metabolism, or poor medication absorption.
Consider measuring plasma concentration for those medications
for which plasma concentration relates to clinical response (e.g.,
If the patient is adhering to treatment and has an adequate
plasma concentration but is not responding to treatment, consider
raising the dose for a finite period (if tolerated) or switching medications.