A 28-year-old man with first-episode psychosis presents with prominent auditory hallucinations, delusions of reference, and disorganized speech for 3 weeks. He has no prior psychiatric history and no medical comorbidities. What is the drug of choice for initiating antipsychotic therapy?
A. Risperidone
B. Chlorpromazine
C. Clozapine
D. Haloperidol
Explanation
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
Table
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-YieldNEET PG
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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