45 - First episode schizophrenia

First-episode schizophrenia

Schizophrenia and related psychoses CHAPTER 1 Either: Agree the choice of antipsychotic medication with patient1 and/or carer Or, if not possible: Start second-generation antipsychotic medication (select one that is available in long-acting injection formulation)2,3 Treatment algorithm Titrate, as necessary, to minimum effective dose (see section on ‘minimum effective dose in this chapter) Adjust dosage regimen according to therapeutic response and tolerability/safety Change drug and follow above process Assess over 2–3 weeks* Clozapine*** If poor adherence related to poor tolerability, discuss with patient and change to drug with more favourable adverse-effect profile When efficacy and tolerability established, switch to long-acting injection Continue at dose established as effective Switch to depot/long-acting injection before discharge** Effective No effect Not effective Not tolerated or poor medication adherence

• Any improvement is likely to be apparent within 2–3 weeks of receiving an effective dose.4 Most improvement occurs during this period.5 If no effect by 2–3 weeks, increase the dose or change the drug. If some response detected, continue for a total of 10 weeks before abandoning treatment.6 ** Relapse and readmission rates are vastly reduced by early use of depot/long-­acting injections in this patient group.7–9 Patients with first-­episode schizophrenia will accept long-­acting injections.10 *** Early use of clozapine much more likely than anything else to be successful.6,11 Reluctance to use clozapine is associated with poor outcomes.12 Delaying the use of clozapine diminishes response to clozapine.13 Treatment algorithms for schizophrenia First-­episode schizophrenia