Schizophrenia · House

Red Flags

Active suicidality, command auditory hallucinations to harm self/others, severe agitation, or violence — admit; same-day psychiatric assessment 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]
First-episode psychosis with neurological signs, atypical features, or onset >40 years — neuroimaging and exclude organic cause (autoimmune encephalitis, metabolic, drug-induced)^[1]

First-line treatment

Interventions

Shared decision making and care plan^[1]
Engage patient and family/carer in treatment plan; recovery-oriented goals; written care plan covering medication, therapy, social support, crisis planning; respect autonomy within safety constraints
Coordinated specialist early intervention service for FEP^[1]
Early intervention reduces relapse and improves outcomes; multidisciplinary team (psychiatrist, CPN, psychologist, social worker, OT, peer support); family intervention
Psychosocial interventions alongside medication^[1]
Cognitive behavioural therapy for psychosis (CBTp), family intervention, supported employment, social skills training, exercise; treat comorbid substance use; address smoking
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

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Olanzapine^[1]	Atypical antipsychotic	5–20 mg PO daily; first-episode start 5 mg	—	Effective broad-spectrum; weight gain and metabolic syndrome are major concerns; sedating; useful in agitated patients; metabolic monitoring
Risperidone^[1]	Atypical antipsychotic	1–6 mg PO daily; first-episode start 1–2 mg	Adolescents per local protocol	Effective, lower metabolic burden than olanzapine; hyperprolactinaemia; long-acting injectable available for adherence
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
Haloperidol (typical)^[1]	Typical antipsychotic	2–20 mg PO daily; acute IM 2.5–5 mg	—	Effective but extrapyramidal side effects, tardive dyskinesia; widely available and cost-effective; ECG monitoring at higher doses
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 antipsychotic trials); haematological monitoring (agranulocytosis); sedation, hypersalivation, weight gain, myocarditis screen, constipation; only on specialist registry
Long-acting injectable antipsychotic^[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; offer at any stage; assess oral tolerability first; bridging oral cover during initiation per agent

Olanzapine^[1]

Atypical antipsychotic

Adult: 5–20 mg PO daily; first-episode start 5 mg
Paediatric: —

Effective broad-spectrum; weight gain and metabolic syndrome are major concerns; sedating; useful in agitated patients; metabolic monitoring

Risperidone^[1]

Atypical antipsychotic

Adult: 1–6 mg PO daily; first-episode start 1–2 mg
Paediatric: Adolescents per local protocol

Effective, lower metabolic burden than olanzapine; hyperprolactinaemia; long-acting injectable available for adherence

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

Haloperidol (typical)^[1]

Typical antipsychotic

Adult: 2–20 mg PO daily; acute IM 2.5–5 mg
Paediatric: —

Effective but extrapyramidal side effects, tardive dyskinesia; widely available and cost-effective; ECG monitoring at higher doses

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 antipsychotic trials); haematological monitoring (agranulocytosis); sedation, hypersalivation, weight gain, myocarditis screen, constipation; only on specialist registry

Long-acting injectable antipsychotic^[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; offer at any stage; assess oral tolerability first; bridging oral cover during initiation per agent

Safety-net

Take medication every day as prescribed; missing doses is the commonest cause of relapse — 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 psychosisEarly intervention in psychosis service / community mental health team^[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

Diagnosis and pharmacological + psychosocial management of schizophrenia, including first-episode psychosis and treatment-resistant illness.

References

1.Indian Psychiatric Society Clinical Practice Guidelines for Management of Schizophrenia (2017, refreshed); NICE CG178; Maudsley Prescribing Guidelines (2022)