Psychiatry · APA

Schizophrenia

APA

Source:American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia, 3rd Edition (2020)

Verified Apr 2026

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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.

References

1.American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia, 3rd Edition (2020) (2020)

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

—

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