Phase 1 — Acute stabilisation & safety
Risk triage first: suicidality, violence/agitation, self‑neglect, command hallucinations, intoxication/withdrawal, medical cause. Choose an antipsychotic by prior response, adverse‑effect fit, comorbidity, and patient preference — there is no universally "best" antipsychotic. Allow an adequate trial (weeks) at an adequate dose before declaring failure.
Phase 2 — Maintenance & relapse prevention
Continue treatment after remission — relapse risk is high on discontinuation and each relapse may erode function. Long‑acting injectables (LAIs) are a rational, non‑punitive choice where adherence or relapse is the issue (and are under‑used). Teach an individualised relapse signature (sleep change, withdrawal, re‑emerging suspiciousness).
Phase 3 — Treatment resistance → clozapine
Failure of ≥2 adequate antipsychotic trials (one atypical) = treatment‑resistant → clozapine, the only agent with superior efficacy here and the most under‑prescribed. It is not risk‑free: mandatory FBC monitoring for agranulocytosis, plus myocarditis, seizures, constipation/ileus (can be fatal), sedation, hypersalivation, metabolic load. "Highly effective" and "needs monitoring" coexist — that's the point of psychiatric prescribing.
Phase 4 — Psychosocial & rehabilitation (co‑primary, not optional)
Psychoeducation, family intervention (reduces relapse where expressed emotion is high), CBT for psychosis, supported employment/education, social‑skills and cognitive remediation. Support autonomy; involve family without displacing the patient.
The treatment pathway (psychosocial care runs alongside throughout):
Adherence as a clinical problem, not a moral failing
"Stopped medication" → ask why: side‑effects, absent insight, cost, stigma, feeling recovered, regimen complexity, substance use, poor alliance. Each cause has a different fix (switch agent, LAI, simplify, psychoeducation, alliance).
The role of ECT here
ECT is not first‑line for schizophrenia; its evidence is strongest for catatonia, severe affective episodes, and treatment‑resistant psychosis as an adjunct. Don't frame it as a schizophrenia "last resort."
Pitfalls
- Delaying clozapine in genuine treatment resistance (the commonest quality gap).
- Discontinuing maintenance too early after a first episode.
Pearls
- 🎯 Two failed adequate trials → clozapine. Don't drift through a third me‑too antipsychotic.
- 🩺 Reach for LAIs early when the problem is relapse/adherence — it's a clinical tool, not a punishment.
Next → The time‑critical mimic you must never miss — delirium, and its separation from dementia and psychosis (Concept 15).