Screen: PHQ-2 → if ≥2, complete PHQ-9
5-9: Watchful waiting, repeat 2-4w
10-14: Moderate - CBT +/− SSRI
15-19: Mod-severe - SSRI + therapy
≥20: Severe - SSRI + referral
First-line: Sertraline 50mg, Escitalopram 10mg
Safety: Ask directly about SI, plan, intent, access. If active → same-day crisis.
≥10: Diagnose GAD. Rule out hyperthyroid, substances, PTSD.
First-line: SSRI/SNRI + CBT. Buspirone adjunct.
Avoid chronic benzos. If needed, ≤2-4w taper.
Panic + agoraphobia → exposure therapy referral.
Never start antidepressant alone if: early onset, postpartum, family history, recurrent depression, antidepressant-induced mania.
MDQ positive → refer psychiatry. Start mood stabilizer, not SSRI.
Red flags: ↓ sleep + ↑ energy, pressured speech, risk-taking.
First-Episode Psychosis Pathway
- History, MSE, risk
- Urine tox, CBC, CMP, TSH, B12, prolactin, ECG
- Rule out delirium, substances
- Risperidone 2mg or Aripiprazole 10mg
- Start low, go slow
- Shared decision-making
- Assess adherence, side effects
- If partial → optimize dose
- If none → switch SGA
- ≥2 adequate trials → clozapine
- Consider LAI for adherence
Chlorpromazine Equivalents
QTc (Bazett)
Metabolic BMI
AIMS Quick Score
Sum items 1-7 (0-4 each). ≥2 in ≥2 areas or ≥3 in 1 = positive.
Antipsychotic Medication Reference
| Drug | Class | Dose | Weight | EPS | Key Notes |
|---|
SGA = second-generation. Metabolic monitoring: weight, waist, BP, fasting glucose, lipids at baseline, 3mo, then yearly.
First-Generation Antipsychotics (FGAs)
FGAs developed 1950s, dopamine D2 blockade, effective for positive symptoms, now largely replaced by SGAs due to EPS/tardive dyskinesia risk, but remain cost-effective and useful in specific scenarios (per TMAP and BAP guidelines).
When to Consider FGAs
- patient preference
- prior good response
- cost/access
- intolerance to metabolic effects of SGAs
- acute agitation (IM haloperidol)
- treatment adherence with LAIs
Dosing Principle
"2-3x minimum effective dose is optimal for acute schizophrenia, balancing efficacy and safety" – note higher doses increase EPS without benefit.
| Drug | Potency | Typical Oral Dose | IM / LAI Dose | Key Side Effects | Monitoring |
|---|---|---|---|---|---|
| Haloperidol | High | 2-20 mg/day oral (ED95 ~13mg/day) | 2-5 mg IM q4-8h acute, decanoate 50-200 mg q4w | EPS high, minimal sedation/weight gain, QTc risk | AIMS q6mo, ECG if IV/high dose, prolactin |
| Fluphenazine | High | 2.5-20 mg/day | Decanoate 12.5-50 mg q2-3w | EPS high | AIMS q6mo |
| Perphenazine | Mid | 8-32 mg/day | — | Moderate EPS, lower cost, shown comparable efficacy in CATIE | AIMS q6mo, prolactin |
| Chlorpromazine | Low | 200-800 mg/day | 25-50 mg IM | High sedation, hypotension, anticholinergic | Orthostatic BP, CBC baseline |
| Thioridazine | Low | 200-600 mg/day | — | High QTc risk, avoid >800mg | ECG mandatory, avoid CYP2D6 inhibitors |
| Trifluoperazine | High | 5-40 mg/day | — | EPS high | AIMS q6mo |
| Thiothixene | High | 5-30 mg/day | — | EPS high | AIMS q6mo |
| Loxapine | Mid | 20-100 mg/day | Inhaled 10mg acute agitation | Moderate EPS, some 5HT2A | AIMS, monitor asthma (inhaled) |
| Molindone | Mid | 50-225 mg/day | — | Lower weight gain | AIMS q6mo |
| Pimozide | High | 2-10 mg/day | — | Tourette's, QTc | ECG baseline & periodic |
Side Effect Management
- EPS: use benztropine 1-2mg BID PRN, avoid routine prophylaxis except high-risk
- Akathisia: propranolol 20-30mg BID, reduce dose
- TD screening: AIMS q6 months
- Hyperprolactinemia: switch to aripiprazole if symptomatic
- NMS: fever, rigidity, CK↑ → stop drug, ICU
Comparison Evidence
Cochrane 2015 found no significant efficacy difference between haloperidol and other FGAs, haloperidol showed less akathisia medium-term. Some FGAs like haloperidol and perphenazine remain cost-effective exceptions where SGAs offer better tolerability.
Cognitive Effects
haloperidol, fluphenazine show poor cognitive improvement in schizophrenia.
Consider SGAs (aripiprazole, lurasidone) if cognition is priority.