Treatment of Side Effects

Medications might be required to treat the extrapyramidal and cholinergic side effects which occur more commonly with the older ''typical'' antipsychotics [11]. Decisions about medications for side effects depend on the severity and degree of distress associated with the side effect and on the availability of other potential strategies, including lowering the dose of the antipsychotic or switching to an alternative.

Some principles in the use of antipsychotic medication are summarized in Table 2.11.

Table 2.11 Principles in the use of antipsychotic medication in early psychosis [3]

• If possible, let the patient (and family) participate in the decision to choose an antipsychotic, however...

• Use novel or "atypical", second-generation antipsychotics as first-line treatment [14,41,57].

• Inform the patient (and family) about the goals of the antipsychotic treatment.

• Inform about the acute and long-term side effects and possible impairment of subjective well-being.

• Monitor side effects closely, especially extrapyramidal symptoms, subjective dysphoria, weight gain and cognitive dysfunction.

• Give repeated psychoeducation about efficacy, tolerability and safety of the antipsychotic.

• Avoid polypharmacy with antipsychotics. Use of more than one antipsychotic should generally be avoided, but concurrent use of a benzodiazepine in the short term, and antidepressant or mood stabilizer in the long term, is commonly necessary and beneficial.

• Avoid multiple or indeterminate prescriptions.

• Use the minimal effective dose to minimize side effects.

• Do not change dose or type of medication impulsively. Wait for at least 3 weeks to assess the response to a given dose or medication change.

• Use for appropriate duration (for example, 1-2 years for antipsychotics).

• Discontinue gradually (4-6 months).

• Follow up after discontinuation (especially in first 3-6 months).

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