Antipsychotic regimens for a first episode of psychosis in adults and young people

For advice on antipsychotic choice for a first episode of psychosis in adults and young people, see here.

Consult a drug information source for advice on contraindications and precautions, and see Principles of antipsychotic use.

#ptg8-c49-s5__tptg8-c49-tbl3 summarises the starting, target and maximum doses of oral antipsychotics for a first episode of psychosis. Some people (eg young people) respond to doses below the target dose.

To treat a first episode of psychosis in an adult or young person, use:

1 amisulpride 100 mg orally, daily; increase to a target dosage of 400 to 600 mg daily in 2 divided doses1. See Monitoring and titrating and Duration of therapy. Maximum daily dose is 1200 mg psychosis, first episode amisulpride amisulpride amisulpride

OR

1 aripiprazole 10 mg orally, in the morning; increase to a target dosage of 15 mg daily. See Monitoring and titrating and Duration of therapy. Maximum daily dose is 30 mg psychosis, first episode aripiprazole aripiprazole aripiprazole

OR

1 quetiapine immediate-release 50 mg orally, twice daily on the first day; increase to 100 mg twice daily on the second day; increase to a target dosage of 200 mg twice daily on the third day2. See Monitoring and titrating and Duration of therapy. Maximum daily dose is 800 mg psychosis, first episode quetiapine quetiapine quetiapine

OR

1 quetiapine modified-release 150 mg orally, daily on the first day; increase to 300 mg daily on the second day; increase to a target dosage of 450 mg daily on the third day2. See Monitoring and titrating and Duration of therapy. Maximum daily dose is 800 mg quetiapine quetiapine quetiapine

OR

1 risperidone 1 mg orally, daily; increase to a target dosage of 2 to 4 mg daily (as a single dose or in 2 divided doses). See Monitoring and titrating and Duration of therapy. Maximum daily dose is 6 mg3Agid 2013 psychosis, first episode risperidone risperidone risperidone

OR

1 ziprasidone 40 mg orally, twice daily; target dosage is 40 to 60 mg twice daily. See Monitoring and titrating and Duration of therapy. Maximum daily dose is 160 mg psychosis, first episode ziprasidone ziprasidone ziprasidone

OR

2 asenapine 5 mg sublingually, twice daily4. See Monitoring and titrating and Duration of therapy. Maximum daily dose is 20 mg5Weber 2009 psychosis, first episode asenapine asenapine asenapine

OR

2 brexpiprazole 1 mg orally, daily for 4 days, then increase to 2 mg daily; target dosage is 2 to 4 mg daily. See Monitoring and titrating and Duration of therapy. Maximum daily dose is 4 mg psychosis, first episode brexpiprazole brexpiprazole brexpiprazole

OR

2 cariprazine 1.5 mg orally, daily; increase to a target daily dosage of 3 mg daily. See Monitoring and titrating and Duration of therapy. Maximum daily dose is 6 mg psychosis, first episode cariprazine cariprazine  

OR

2 lurasidone 40 mg orally, daily; increase to a target dosage of 80 to 120 mg daily. See Monitoring and titrating and Duration of therapy. Maximum daily dose is 160 mg psychosis, first episode lurasidone lurasidone lurasidone

OR

2 paliperidone modified-release 3 to 6 mg orally, daily; target dosage is 6 mg daily6. See Monitoring and titrating and Duration of therapy. Maximum daily dose is 12 mg psychosis, oral paliperidone paliperidone paliperidone

OR

3 olanzapine 5 mg orally, daily; increase to a target dosage of 10 to 15 mg daily. See Monitoring and titrating and Duration of therapy. Maximum daily dose is 20 mg7. psychosis, first episode olanzapine olanzapine olanzapine

1 The amisulpride product information recommends a starting dose of 400 mg; a lower starting dose is recommended in these guidelines to improve tolerability, but a higher dose may be used depending on the acuity of the patient's presentation. Although doses above 400 mg are recommended to be given in 2 divided doses, in practice, a once-daily regimen is sometimes used if adherence is poor.Return
2 To achieve an adequate clinical response, a total daily quetiapine dose between 400 to 600 mg is frequently needed.Return
3 Trials of risperidone for a first episode of psychosis used a twice-daily regimen, and this is recommended in the product information. However, in practice, a once-daily regimen is often used if adherence is poor.Return
4 The starting dosage of asenapine (5 mg sublingually, twice daily) is also the target dosage.Return
5 Asenapine wafers should not be swallowed—efficacy relies on sublingual absorption.Return
6 The paliperidone product information recommends a starting dose of 6 mg; these guidelines allow for a lower starting dose to improve tolerability.Return
7 Although the licensed maximum daily dose of olanzapine is 20 mg, a total daily dose of 30 mg may be used if managing agitation or under psychiatrist advice for treatment-resistant schizophrenia.Return