Choosing and monitoring an antipsychotic in first-episode psychosis (MEQ)

(i) Choice. Prefer a metabolically lighter option given BMI 31 and weight concerns, with attention to sexual/prolactin effects — e.g. aripiprazole 10 mg orally daily (partial agonist; relatively prolactin-sparing; watch akathisia). Justify using effectiveness literature: SGAs are not universally superior (CATIE/CUtLASS), but EUFEST supports better discontinuation than haloperidol in FEP for several SGAs; Leucht NMA frames efficacy–tolerability trade-offs. Avoid opening with olanzapine solely for convenience given metabolic risk.^[1][2][3]

(ii) Monitoring. Baseline weight/BMI/waist, BP, glucose/HbA1c, lipids, FBC, U&E, LFT, ECG if indicated, pregnancy test if relevant. Early review for akathisia, efficacy, adherence; metabolic recheck ~3 months then ongoing.^[3]

(iii) Adequate trial. Therapeutic dose for typically 4–6 weeks with adherence confirmed. If fails, switch profile (not random polypharmacy). Document substance use and diagnostic review as pseudo-resistance checks.^[4]

(iv) LAI and clozapine. Offer LAI when adherence risk threatens relapse or patient prefers, after oral tolerability. After two adequate failed trials, assess TRRIP treatment resistance and offer clozapine with monitoring — do not endlessly cycle non-clozapine agents.^[4]

(v) Acute dystonia. Recognise; ensure airway; give parenteral anticholinergic per local protocol; hold/reduce offending agent; reassure; review ongoing regimen.^[3]