Optimizing Outcome with Antipsychotic Treatment in First-Episode Schizophrenia: Balancing Efficacy and Side Effects

Clinical Schizophrenia & Related Psychoses 10/2012; 6(3):115-121. DOI: 10.3371/CSRP.6.3.3


The initial tailoring of antipsychotic medication for an individual experiencing a first episode of psychosis (FEP) is a critical empirical process with potentially far-reaching consequences. This article reviews the results of randomized treatment trials of clinically available first-generation antipsychotics (FGAs) and second-generation antipsychotics (SGAs) in individuals experiencing FEP, addressing these medications' relative therapeutic potentials and their proclivities to produce a range of unwanted side effects. The authors will argue that the best clinical long-term outcomes will be achieved with: 1) a "succeed-first" strategy of identifying those treatment-responsive individuals who will have a good response to neuroleptic threshold doses of well-tolerated FGAs (thereby avoiding weight gain, insulin resis tance, and prolactin-induced changes in gender-specific physiology); and, 2) an early trial of clozapine in treatment-nonresponsive FEP patients.

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    • "Most patients with schizophrenia need long-term treatment with antipsychotic medication. However, weight gain and hyperprolactinemia are common side effects of many modern antipsychotics and are common complaints among patients with schizophrenia treated with antipsychotics.[1] Short-term studies have shown that weight gain and hyperprolactinemia are more prominent among female patients of reproductive age.[2][3] "
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    ABSTRACT: Increased serum prolactin and weight gain are common side effects of atypical antipsychotics but few studies have assessed the long-term pattern of these adverse effects.
    Shanghai Archives of Psychiatry 04/2014; 26(2):88-94. DOI:10.3969/j.issn.1002-0829.2014.02.005
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    ABSTRACT: Objective: Better understanding of the temporal development of cardiovascular risk will permit more targeted prevention of premature cardiovascular mortality in schizophrenia. Methods: The sample for this analysis was drawn from referrals (between 2006 and '11) to an early psychosis clinic based in a U.S. urban community mental health center. 76 individuals with schizophrenia who were young (mean 22.4 years, SD 4.8), early course (median duration of illness 31 weeks) and with minimal prior antipsychotic exposure (median 2 weeks) were compared to age-, gender-, and race-matched peers drawn from the National Health and Nutrition Survey (2007-'08). Measures of cardiovascular risk at baseline, 6 months, and 1 year are reported. Results: While indistinguishable from peers at entry, patients suffered pervasive adverse trajectories of cardiovascular risk factors over the subsequent year. 16 of 44 initial non-smokers became nicotine dependent and none of 32 entering smokers quit. 17 patients transitioned to overweight (BMI 25-29.9, n = 3) or obese (BMI>30, n = 14) categories, while only 24 of 38 (63%) sustained normal weight over one year. Similar adverse trends in blood pressure, lipids, and fasting glucose led to an increase in prevalence of metabolic syndrome (1.31% to 5.26%). 10-year cardiovascular risk estimates showed a small and significant increase although remaining in the low risk (<10%) category. Conclusions: The early emergence of obesity and smoking in younger schizophrenia samples provides a rational focus for primary prevention of premature cardiovascular mortality. The first year of treatment constitutes the beginning of a critical period for such preventive efforts.
    Schizophrenia Research 02/2013; 146(1-3). DOI:10.1016/j.schres.2013.01.014 · 3.92 Impact Factor
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    ABSTRACT: Clozapine remains the treatment of choice in refractory schizophrenia despite its various requirement to prescribe, such as mandatory blood monitoring program and various metabolic complication. Currently, clozapine is recommended only after two failed adequate antipsychotics trials. We report a case of a successful early clozapine trial in the treatment of first-episode schizophrenia patient, considering poor treatment response and repeated self-injurious behavior. This case highlights the efficacy of an early clozapine trial as a second-line treatment for first-episode schizophrenia in contrast to switching or combination treatment strategy.
    Clinical Psychopharmacology and Neuroscience 12/2013; 11(3):168-9. DOI:10.9758/cpn.2013.11.3.168
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