5
Recommendations for Acute Phase Treatment
Î Rapid emergency treatments for acutely psychotic patients showing
aggressive behaviors:
• Short-acting parenteral antipsychotic with or without parenteral benzodiazepine
and with or without parenteral anticholinergic
• Rapidly dissolving oral formulations or oral concentrates of atypical antipsychotics
Î Use atypical antipsychotics as first-line treatment
• Atypical antipsychotics may have superior efficacy for treating cognitive, negative,
and affective symptoms
• Use lower doses in 1st episode individuals because they are more sensitive to EPS
and metabolic side effects
• For some patients, conventional antipsychotics may be 1st choice
Note: Conventional antipsychotics may be as effective as atypical antipsychotics for
acute phase treatment.
Î Clozapine should be used in patients with persistent suicidality,
violence, or substance abuse
Note: Clozapine tends to be under-utilized in some treatment settings, or utilized
later than recommended (ie, following multiple antipsychotic treatment failures
rather than just two or three).
Î Clozapine augmentation with an atypical or a conventional agent or ECT
should be preceded by a treatment-refractory evaluation including:
Note: Clozapine may also be superior for treatment-resistant symptoms.
Î Use long-acting injectable formulations of initial oral medication for
patients with adherence issues, violent behavior, or even in early-
onset schizophrenia.
• Clozapine serum levels
• Re-examining diagnosis
• Substance abuse
• Treatment adherence
• Psychosocial stressors
