Guidance:
1.1 The choice of antipsychotic drug should be made jointly by the individual and the clinician responsible for treatment based on an informed discussion of the relative benefits of the drugs and their side-effect profiles. The individuals advocate or carer should be consulted where appropriate.
1.2 It is recommended that the oral atypical antipsychotic drugs amisulpride, olanzapine, quetiapine, risperidone and zotepine are considered in the choice of first-line treatments for individuals with newly diagnosed schizophrenia.
1.3 The oral atypical antipsychotic drugs listed in section 3.3 of the report should be considered as treatment options for individuals currently receiving typical antipsychotic drugs who, despite adequate symptom control, are experiencing unacceptable side effects, and for those in relapse who have previously experienced unsatisfactory management or unacceptable side effects with typical antipsychotic drugs. The decision as to what are unacceptable side effects should be taken following discussion between the patient and the clinician responsible for treatment.
1.4 It is not recommended that, in routine clinical practice, individuals change to one of the oral atypical antipsychotic drugs if they are currently achieving good control of their condition without unacceptable side effects with typical antipsychotic drugs.
1.5 In individuals with evidence of treatment-resistant schizophrenia (TRS), clozapine should be introduced at the earliest opportunity. TRS is suggested by a lack of satisfactory clinical improvement despite the sequential use of the recommended doses for 6 to 8 weeks of at least two antipsychotics, at least one of which should be an atypical.
1.6 A risk assessment should be performed by the clinician responsible for treatment and the multidisciplinary team regarding concordance with medication, and depot preparations should be prescribed when appropriate.
1.7 Where more than one atypical antipsychotic drug is considered appropriate, the drug with the lowest purchase cost (taking into account daily required dose and product price per dose) should be prescribed.
1.8 When full discussion between the clinician responsible for treatment and the individual concerned is not possible, in particular in the management of an acute schizophrenic episode, the oral atypical drugs should be considered as the treatment options of choice because of the lower potential risk of extrapyramidal symptoms (EPS). In these circumstances, the individuals carer or advocate should be consulted where possible and appropriate. Although there are limitations with advanced directives regarding the choice of treatment for individuals with schizophrenia, it is recommended that they are developed and documented in individuals care programmes whenever possible.
1.9 Antipsychotic therapy should be initiated as part of a comprehensive package of care that addresses the individual's clinical, emotional and social needs. The clinician responsible for treatment and key worker should monitor both therapeutic progress and tolerability of the drug on an ongoing basis. Monitoring is particularly important when individuals have just changed from one antipsychotic to another.
1.10 Atypical and typical antipsychotic drugs should not be prescribed concurrently except for short periods to cover changeover of medication.