Red Flags
- Active suicidality, command auditory hallucinations to harm self/others, severe agitation, or violence — same-day psychiatric admission under appropriate legal framework[1]
- Catatonia (mutism, posturing, stupor, waxy flexibility) — emergency benzodiazepine challenge (lorazepam); rule out medical causes; consider ECT[1]
- Neuroleptic malignant syndrome (rigidity, fever, autonomic instability, raised CK) — stop antipsychotic; admit to ITU; supportive care, dantrolene/bromocriptine[1]
- Tardive dyskinesia or sustained extrapyramidal symptoms — review antipsychotic; consider VMAT2 inhibitor (deutetrabenazine, valbenazine); reduce or switch agent[1]
First-line treatment
Interventions
- Shared decision making and recovery-oriented care plan[1]Engage patient and family/carer in goal-setting; written plan covering medication, therapy, social support, crisis planning; respect autonomy within safety constraints
- Coordinated specialty care (CSC) for first-episode psychosis[1]Multidisciplinary team (psychiatrist, therapist, supported employment specialist, family clinician); recovery-oriented; family psychoeducation; medication support; reduces relapse and improves outcomes
- Psychosocial interventions alongside medication[1]Cognitive behavioural therapy for psychosis (CBTp), family intervention, supported employment and education, social skills training, assertive community treatment for high need; cognitive remediation
- Annual physical health monitoring[1]Schizophrenia confers 15–20 year mortality gap, mostly cardiovascular and metabolic. Monitor weight, BP, glucose, lipids, smoking; primary-care led management of cardiovascular risk and smoking cessation
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Risperidone[1] | Atypical antipsychotic | 1–6 mg PO daily; first-episode start 1–2 mg | Adolescents per local protocol | Effective broad-spectrum; lower metabolic burden than olanzapine; hyperprolactinaemia; long-acting injectable available for adherence |
| Olanzapine[1] | Atypical antipsychotic | 5–20 mg PO daily; first-episode start 5 mg | — | Effective, sedating; weight gain and metabolic syndrome major concerns; useful in agitated patients; metabolic monitoring |
| Aripiprazole[1] | Atypical antipsychotic / partial dopamine agonist | 10–30 mg PO daily; first-episode start 10 mg | — | Lower metabolic burden, lower prolactin elevation; activating — initial restlessness; long-acting injectable available |
| Clozapine (treatment-resistant)[1] | Atypical antipsychotic | 12.5 mg PO night start, titrate slowly to 200–450 mg/day; specialist clozapine clinic | — | Treatment-resistant schizophrenia (failure of ≥2 adequate trials); haematological monitoring (agranulocytosis); sedation, hypersalivation, weight gain, myocarditis screen, constipation; only on specialist registry |
| Long-acting injectable antipsychotic (LAI)[1] | Depot antipsychotic | Risperidone LAI 25–50 mg IM every 2 weeks; aripiprazole 400 mg IM monthly; paliperidone palmitate 100–150 mg IM monthly; haloperidol decanoate 50–200 mg IM monthly | — | Adherence-related relapse; APA explicitly recommends offer at any stage including first-episode psychosis; assess oral tolerability first; bridging oral cover during initiation per agent |
| Deutetrabenazine or valbenazine (tardive dyskinesia)[1] | VMAT2 inhibitor | Deutetrabenazine 6 mg PO BD start, titrate to 12–24 mg BD; valbenazine 40 mg PO daily, titrate to 80 mg | — | Persistent or moderate-severe tardive dyskinesia; specialist initiation; QTc and depression monitoring; dose-related sedation |
Risperidone[1]
Atypical antipsychotic
- Adult
- 1–6 mg PO daily; first-episode start 1–2 mg
- Paediatric
- Adolescents per local protocol
Effective broad-spectrum; lower metabolic burden than olanzapine; hyperprolactinaemia; long-acting injectable available for adherence
Olanzapine[1]
Atypical antipsychotic
- Adult
- 5–20 mg PO daily; first-episode start 5 mg
- Paediatric
- —
Effective, sedating; weight gain and metabolic syndrome major concerns; useful in agitated patients; metabolic monitoring
Aripiprazole[1]
Atypical antipsychotic / partial dopamine agonist
- Adult
- 10–30 mg PO daily; first-episode start 10 mg
- Paediatric
- —
Lower metabolic burden, lower prolactin elevation; activating — initial restlessness; long-acting injectable available
Clozapine (treatment-resistant)[1]
Atypical antipsychotic
- Adult
- 12.5 mg PO night start, titrate slowly to 200–450 mg/day; specialist clozapine clinic
- Paediatric
- —
Treatment-resistant schizophrenia (failure of ≥2 adequate trials); haematological monitoring (agranulocytosis); sedation, hypersalivation, weight gain, myocarditis screen, constipation; only on specialist registry
Long-acting injectable antipsychotic (LAI)[1]
Depot antipsychotic
- Adult
- Risperidone LAI 25–50 mg IM every 2 weeks; aripiprazole 400 mg IM monthly; paliperidone palmitate 100–150 mg IM monthly; haloperidol decanoate 50–200 mg IM monthly
- Paediatric
- —
Adherence-related relapse; APA explicitly recommends offer at any stage including first-episode psychosis; assess oral tolerability first; bridging oral cover during initiation per agent
Deutetrabenazine or valbenazine (tardive dyskinesia)[1]
VMAT2 inhibitor
- Adult
- Deutetrabenazine 6 mg PO BD start, titrate to 12–24 mg BD; valbenazine 40 mg PO daily, titrate to 80 mg
- Paediatric
- —
Persistent or moderate-severe tardive dyskinesia; specialist initiation; QTc and depression monitoring; dose-related sedation
Safety-net
- Take medication every day as prescribed; long-acting injection is an option if remembering daily is difficult[1]
- Tell your prescriber about new symptoms (stiffness, restlessness, tremor, muscle pain, sudden fever, rapid weight gain, loss of menstrual periods) — manageable with adjustment[1]
- Smoking cessation, dietary advice, and exercise reduce the cardiovascular gap; offer help with these alongside medication[1]
Referral criteria
- All first-episode psychosisCoordinated specialty care / first-episode psychosis service[1]
- Treatment-resistant schizophrenia (failure of ≥2 antipsychotics at adequate dose and duration)Specialist clozapine clinic[1]
- Acute risk to self or others, severe agitation, catatonia, or NMSEmergency department; admission under appropriate legal framework[1]
- Pregnancy or planning pregnancy on antipsychoticPerinatal mental health and obstetric clinic[1]
Clinical summary
Comprehensive assessment, antipsychotic selection, and integrated psychosocial treatment of adults with schizophrenia per APA 2020 guideline.