Schizophrenia
Chronic psychiatric disorder with positive (delusions, hallucinations), negative (apathy, avolition), and cognitive symptoms. Diagnosed by ICD-10 or DSM-5 criteria after excluding organic causes.
ICD-10 F209 drugs
Also known as: Schizophrenia spectrum disorder
Drugs used for this condition
- AAmisulprideFirst line · Atypical antipsychotic of the benzamide classAtypical antipsychotic for schizophrenia, including the negative-symptom predominant form. Meta-analyses confirm its efficacy, including in prominent negative symptoms. Watch the QT interval and prolactin.
- AAripiprazoleFirst line · Atypical antipsychotic – dopamine partial agonistFirst-line for schizophrenia and schizoaffective disorder per APA 2020 and NICE NG178 (2020). Starting dose 10–15 mg once daily, titrated to 15–30 mg. Long-acting injectable (Abilify Maintena 400 mg every 4 weeks) for patients with adherence issues. The Huhn 2019 network meta-analysis showed efficacy comparable to other atypical antipsychotics with better metabolic profile.
- AHaloperidolFirst line · First-generation antipsychotics. Butyrophenone derivativesHaloperidol is used in schizophrenia for acute positive symptom control and maintenance therapy. APA 2020 and NICE CG178 list haloperidol as a standard first-generation antipsychotic; current guidelines favor atypical antipsychotics as first-line due to a more favorable side-effect profile, but haloperidol retains its role when parenteral administration is required and in resource-limited settings. The decanoate form provides a 4-week depot effect for patients with poor adherence.
- AOlanzapineFirst line · Atypical antipsychotic – thienobenzodiazepineFirst-line for schizophrenia and schizoaffective disorder per APA 2020 and NICE NG178 (2020). Starting dose 5–10 mg once daily at bedtime, titrated to 10–20 mg. Among the most effective atypical antipsychotics (Huhn 2019), but choice is individualized due to metabolic adverse effects. In patients at metabolic syndrome risk, aripiprazole is preferred.
- APaliperidoneFirst line · Atypical antipsychotic – active metabolite of risperidoneFirst-line for schizophrenia per APA 2020 and NICE NG178. Starting dose 6 mg once daily in the morning (OROS form – do not break), therapeutic range 3–12 mg. Long-acting injectables are the main advantage over risperidone: Xeplion (paliperidone palmitate) monthly, Trevicta every 3 months, Byannli every 6 months – convenient with adherence issues. The Huhn 2019 network meta-analysis showed efficacy comparable to risperidone; prolactin-related effects are similar.
- AQuetiapineFirst line · Atypical antipsychoticsAPA 2020 and NICE CG178 offer atypical antipsychotics as a first-choice option from the start, guided by tolerability and patient preference; quetiapine is one acceptable option among them. Start 25 mg twice daily; target 300–800 mg daily. Between-drug efficacy differences are generally modest, but in network meta-analyses (Leucht 2013, Huhn 2019) quetiapine ranks toward the lower-efficacy end; safer than haloperidol or risperidone for extrapyramidal side effects; less favorable metabolic profile (weight gain, dyslipidemia, dysglycemia).
- ARisperidoneFirst line · Atypical antipsychotic – dopamine and serotonin receptor antagonistFirst-line for schizophrenia per APA 2020 and NICE NG178 (2020). Starting dose 2 mg once daily, titrated to 4–6 mg. Long-acting injectable Risperdal Consta 25–50 mg every 2 weeks for patients with adherence issues. The Huhn 2019 network meta-analysis showed one of the highest efficacies among atypical antipsychotics, but a worse side-effect profile than aripiprazole – more prolactinemia, metabolic disturbance, and extrapyramidal effects at high doses.
- AZiprasidoneSecond line · Atypical antipsychotic – indole derivativeSecond-line for schizophrenia per APA 2020. Starting dose 20 mg twice daily, titrated to 40–80 mg twice daily. Advantage: minimal metabolic impact; preferred in patients with metabolic syndrome, obesity, diabetes. Huhn 2019 network meta-analysis showed lower efficacy than olanzapine and risperidone but better metabolic tolerability.
- BChlorpromazineThird line · First-generation antipsychotic, aliphatic-side-chain phenothiazineChlorpromazine is third-line antipsychotic for schizophrenia. SEPB reserves it after atypical APs due to high rates of extrapyramidal symptoms, hyperprolactinaemia and QT prolongation. Also used in acute agitation and hiccup.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit