## First-Line Antipsychotic Selection in First-Episode Psychosis **Key Point:** Second-generation (atypical) antipsychotics are the first-line agents for first-episode schizophrenia due to superior efficacy-to-side-effect ratio compared to first-generation agents. ### Why Risperidone? Risperidone is preferred as a first-line agent because it: - Has established efficacy in acute psychosis with rapid symptom control - Carries lower risk of extrapyramidal side effects (EPS) compared to haloperidol - Has minimal metabolic side effects at standard doses (0.5–6 mg/day) - Is well-tolerated in first-episode patients, improving adherence - Has good oral bioavailability and predictable pharmacokinetics ### Comparison of Antipsychotics | Agent | Class | EPS Risk | Metabolic Risk | First-Line? | |-------|-------|----------|----------------|-------------| | **Risperidone** | **Atypical** | **Low–moderate** | **Low** | **Yes** | | Haloperidol | Typical | Very high | Minimal | No (historical) | | Chlorpromazine | Typical | High | Moderate | No (historical) | | Clozapine | Atypical | Very low | Very high | No (reserved for TRD) | **High-Yield:** Current guidelines (NICE, APA, Indian Psychiatric Society) recommend atypical antipsychotics (risperidone, olanzapine, quetiapine, aripiprazole) over typical agents for first-episode psychosis. Risperidone and olanzapine are most commonly used due to robust evidence and tolerability. **Clinical Pearl:** Clozapine is reserved for treatment-resistant schizophrenia (failure of ≥2 adequate trials of different antipsychotics), not first-line use, due to agranulocytosis risk and need for regular monitoring. **Tip:** In NEET PG, when a first-episode psychosis stem does not mention treatment resistance, prior antipsychotic failure, or severe metabolic concerns, the answer is almost always an atypical agent (risperidone, olanzapine, or aripiprazole).
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