You have completed the assessment for (and, if necessary, management of) certain side effects that could be contributing to the overall unsatisfactory response of this patient. Or, you could have landed here because the patient had a breakthrough of symptoms on their current dose of antipsychotic. You will now be asked to identify the antipsychotic the patient is on, and a determination will be made as to whether this has been an adequate trial of this antipsychotic. If it is an adequate trial, you will be asked to consider whether it would be worth trying a different antipsychotic. If there have been at least two trials with different antipsychotics that are adequate, clozapine may be appropriate to consider. if the patient is on clozapine now, a sequence of steps to deal with unsatisfactory response to clozapine will be presented.
The algorithm stresses sequential monotherapy of up to several antipsychotics, as this is the most evidence-supported and expert-endorsed approach. You may be thinking of adding an adjunctive medication, such as an antidepressant if the patient is showing some depressive symptoms, or combining two antipsychotics. The evidence generally does not support that practice, even though it is common.(1,2) The algorithm will present adjunctive treatments as an option to consider after the patient has had enough monotherapy trials to meet minimal criteria for consideration of clozapine.
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1. Osser DN, Sigadel R. Short-term inpatient pharmacotherapy of schizophrenia. Harvard Review of Psychiatry 2001:9:89-104. 2. Levinson DF, Umapathy C, Musthaq M. Treatment of schizoaffective disorder and schizophrenia with mood symptoms. Am J Psychiatry 1999;156:1138-48.