Key Points
Î Consider other psychiatric disorders in making a differential diagnosis
Î Form and engage in a therapeutic alliance and encourage a supportive
social network in order to improve long-term outcomes
Î Reassess frequently, especially if a definitive diagnosis cannot be
made or if diagnosis was made in the last 12 months
Î Actively monitor for and treat comorbid conditions including
substance abuse
Î Integrate treatments from multiple clinicians, especially for comorbid
conditions
Î For 1st episode schizophrenia initiate treatment with atypical
antipsychotics in lower doses as appropriate
Î Use conventional antipsychotics only after at least one unsuccessful
trial with an atypical antipsychotic
Î Strongly consider clozapine after two unsuccessful antipsychotic trials
Assessment
Î Assessment
• Evaluate causes for psychotic episode
• Interview individuals close to the patient if feasible
• Verify the diagnosis
• Complete psychiatric and general medical history and status
• Identify comorbid psychiatric and medical conditions
▶ Substance use (eg, marijuana)
▶ Infectious disease (eg, syphilis, HIV)
• Evaluate general medical health
• Evaluate suicide risk
• Assess likelihood for dangerous, impulsive, or aggressive behavior
• Identify patient strengths and limitations
• Assess baseline values that may be affected by antipsychotic treatment
▶ Vital signs
▶ Weight, height, body mass index (BMI), waist circumference
▶ Extrapyramidal symptoms
▶ Tardive dyskinesia (AIMS)
▶ Diabetes risk factors
▶ Cognition (MMSE)
▶ Hyperprolactinemia
▶ Lipid panel
▶ ECG and serum potassium and magnesium
▶ Ocular exam
▶ Screen for changes in vision
▶ Pregnancy and sexually transmitted disease (STD)
• Consider brain imaging for patients with a new onset of psychosis or atypical
clinical presentation
• Engage in therapeutic alliance
