7
Figure 1. Antipsychotic Algorithm for Schizophrenia
4-6 wk trial of another
atypical or conventional
antipsychotic
Maintenance Phase
• Suicide risk
• Severe agitation or violence
• Use of long-acting depots
• Non-adherence
• Depression or mood symptoms
• Substance abuse
• Prodromal or first episode psychosis
is more likely to respond but can
experience a greater frequency/
intensity of adverse effects
• Catatonia or neuroleptic
malignant syndrome (NMS)
Consider at each stage:
Efficacy Tolerability
6 month trial of
clozapine
(≤ 900 mg/day)
Optimize clozapine
and/or add ECT,
adjunct prescription, or
alternate strategies
Inadequate
response
Inadequate
response
Inadequate
response
Intolerable
movement
disorder
clozapine,
iloperidone, or
quetiapine
Intolerable
metabolic
syndrome
Intolerable
sedation
Adequate
response
First-episode schizophrenia or schizoaffective disorder
4-6 wk trial of a single atypical antipsychotic or, if not available, a trial of
haloperidol, chlorpromazine, or other conventional antipsychotic
LOWEST RISK: aripiprazole,
lurasidone, or ziprasidone
LOWER RISK: lurasidone or
paliperidone ER
LOWEST RISK: aripiprazole,
lurasidone, or ziprasidone
LOWER RISK: asenapine,
iloperidone, or paliperidone ER
