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Special Circumstances
Treatment-resistant Patients
Î Assess for adequate dose and treatment adherence
Î Consider clozapine
• For patients with an inadequate response to 2 antipsychotics (at least one of which
is an atypical antipsychotic)
• For patients with persistent suicidality
Î Augmentation with another antipsychotic, anticonvulsant,
or a benzodiazepine
Î Electroconvulsive therapy (ECT)
Î Cognitive remediation therapy (CRT)
Î Cognitive behavior therapy (CBT)
Negative Symptoms
Î Assess for factors that may contribute to negative symptoms
• Treat with antipsychotics if secondary to positive symptoms
• Treat with antidepressants if secondary to depression
• Treat with anxiolytics if secondary to anxiety
• Treat with antiparkinsonian agents or antipsychotic dose reduction if secondary
to EPS
Î If negative symptoms are primary
• Consider treatment with clozapine or other atypical antipsychotics
Î Adjunctive treatment for negative symptoms
• SSRI, SNRI, or another antipsychotic
Relapse
Î When taking oral antipsychotic
• Switch to a different oral antipsychotic or increase dose of the current
antipsychotic
• If treatment nonadherence is suspected
▶ Switch to a depot atypical antipsychotic
▶ Switch to a depot conventional antipsychotic
• When taking a depot antipsychotic
▶ Switch from depot conventional to depot atypical antipsychotic
▶ Increase dose or frequency of injections
▶ Supplement with oral formulation of the same antipsychotic
