Treatment
6
Î Adjunctive medications in the acute phase
• For comorbid conditions
▶ Major depression
Note: Some antidepressants may sustain or exacerbate psychotic symptoms
▶ Other comorbidities
• For certain symptom domains
Notes: Benzodiazepines may be helpful for anxiety and agitation, particularly
short-term but monitor for dependence or abuse; also reported to increase mortality
with long-term use.
Mood stabilizers and beta-blockers may be useful for hostility and aggression.
• For sleep disturbances
• For extrapyramidal side effects (EPS) especially dystonia and Parkinsonism
▶ For prophylactic treatment of EPS, consider:
» Propensity of the antipsychotic to cause EPS
» Patient preference
» Patient's history of EPS
» Other risk factors for EPS
» Risk factors for and consequences of anticholinergic side effects
▶ Consider lowering antipsychotic dose or switching to a different antipsychotic.
• For patients with persistent severe psychosis or suicidal ideation
▶ Add electroconvulsive therapy (ECT) in the acute phase
Î Special issues in the treatment of first-episode patients
• Careful documentation of symptoms, which may evolve over time
• Predictors of poor treatment response
• Attempt to minimize risk of relapse in remitted patients
• Alleviate exposure to cannabinoids and psychostimulants
• Enhance stress management
• Maintenance antipsychotic treatment
• Patient education
▶ Factors that increase relapse risk
▶ Indefinite antipsychotic maintenance treatment
▶ Medication discontinuation with close follow-up and a plan of antipsychotic
reinstitution with symptom recurrence
• Consider using a long-acting depot formulation
▶ Male gender
▶ Prenatal or perinatal injury
▶ Severe hallucinations and delusions
▶ Attentional impairments
▶ Lack of affective component
▶ Poor premorbid functioning
▶ Longer duration of untreated psychosis
▶ Development of EPS
▶ Distressing emotional environment
▶ Agitation
▶ Aggression
▶ Affective symptoms
▶ Other symptoms
