Select and evaluate an oral antipsychotic collaboratively during acute psychosis, complete cardiovascular, metabolic, movement and reproductive safety assessment, recognise serious adverse reactions, and change one variable at a time using an explicit therapeutic trial.
Medication is one part of acute psychosis care. Address communication, sleep, food, fluids, substances, physical illness, housing and safety while offering psychological support. Explain the likely benefits and important harms of available oral antipsychotics in language the person can use. Previous benefit, adverse reactions, family experience and personal priorities matter. Some people prioritise avoiding weight gain, prolactin effects or sedation; others value sleep or a formulation they already trust. Decision-making support and capacity assessment concern the particular choice, not the diagnosis alone.
Create a baseline that allows later change to be interpreted. Record weight and waist circumference, pulse and blood pressure, nutritional status and activity. Measure fasting glucose or HbA1c and lipid profile, assess movement disorders and obtain prolactin. Review smoking, alcohol and substances, prescribed and over-the-counter medicines, pregnancy possibility and sexual or reproductive concerns. NICE specifies ECG before treatment when the product information requires it, cardiovascular examination or risk is present, personal cardiovascular history exists, or the person is being admitted as an inpatient.
Reduced distress, conviction, hallucination burden, disorganisation or dangerous behaviour appears alongside improved sleep, engagement and everyday function over the agreed trial.
Subjective inner restlessness with observable pacing or repetitive movement can resemble worsening agitation and requires direct questioning and medicine review.
Rigidity, tremor, bradykinesia or acute sustained muscle contractions indicate extrapyramidal effects whose timing and severity guide urgent or planned action.
Rapid appetite or weight increase, rising glucose and adverse lipids may occur early and require active intervention before long-term cardiovascular burden accumulates.
Menstrual disturbance, galactorrhoea, sexual dysfunction or reduced libido may reflect prolactin elevation and can profoundly affect adherence and wellbeing.
Monitor akathisia, activation, impulse-control symptoms, nausea and insomnia, review CYP2D6 and CYP3A4 interactions, and still complete weight, glucose, lipid, cardiovascular and movement surveillance.
Prolactin elevation, sexual or menstrual effects, extrapyramidal symptoms, orthostasis and metabolic change require discussion and monitoring; reduce and titrate cautiously in renal or hepatic impairment.
A quieter interview after medication can reflect drowsiness while delusions, fear and function remain unchanged, so target outcomes must be reviewed directly.
Unrecognised inner restlessness may be labelled agitation or non-adherence and can worsen subjective distress after an otherwise reasonable prescription.
Past weight gain, sexual effects or emotional blunting can legitimately determine choice because acceptability influences sustained exposure and recovery.
Pre-existing tremor, obesity or hyperprolactinaemia cannot be distinguished from treatment change unless they were assessed before or promptly after initiation.
Simultaneous dose changes and polypharmacy make benefit and harm harder to attribute and leave future clinicians with an uninterpretable trial.
Choosing a drug solely by habit without discussing adverse-effect priorities and previous experience.
Calling sedation or containment a therapeutic response without reassessing psychosis and function.
Missing akathisia because pacing is assumed to represent worsening illness or deliberate disruption.
Recording abnormal weight or glucose without assigning treatment, review and communication responsibility.
Using routine combined antipsychotics to compensate for an undocumented inadequate single-drug trial.
Declaring treatment resistance before confirming two sequential adequate trials and actual adherence.
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An antipsychotic-naive adult with first-episode psychosis is considering oral treatment. Which set best represents the physical baseline that should be recorded before prescribing where feasible?
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes
Prescribe an explicit therapeutic trial. Document the medicine, licensed indication, target symptoms, starting dose, any titration and the expected time for review. Begin toward the lower end of the licensed range unless clinical reasons support otherwise and justify doses outside the BNF or SmPC range. Avoid a loading dose. Do not initiate routine regular combined antipsychotics except for short periods such as a documented switch. Check adherence and exposure rather than interpreting a prescription as proof that the person took an adequate course.
Monitor benefit and harm together. Ask about voices, beliefs, thought organisation, agitation, sleep, self-care and function, and also sedation, akathisia, dystonia, parkinsonism, tardive movement, appetite, weight, sexual function and menstrual change. Measure pulse and blood pressure after relevant dose changes. Follow the structured metabolic schedule and communicate results. A person can have biochemical deterioration without symptoms. Intervene through shared lifestyle support, primary-care management and reconsideration of the antipsychotic burden rather than merely recording abnormal results.
When improvement is insufficient, revisit the formulation. Delirium, affective illness, substances, trauma, catatonia and neurological disease may have been missed. Confirm dose, duration, adherence and absorption and whether adverse effects prevent actual use. Discuss optimisation or a single-drug switch, with cross-taper and interaction planning. An emergency behavioural episode follows the separate rapid-tranquillisation protocol, including continuous post-administration monitoring and cumulative dose review; it should not become the undocumented maintenance regimen.