QUESTION

Psychosis    

How would you educate the parents about the diagnosis and prognosis of the patient who had the first psychotic episode?
List at least two community resources in your area that would help a child who has been diagnosed with schizophrenia. Include links if available online. If you live in a rural area and cannot find anything available locally, you may look for online resources or for resources for their parents. Provide evidence of having searched for local child-centered resources first.

Early-Onset Psychosis Transcript

[Lyrics] And the brain keeps learning, learning and learning, learning.

Stephen Stahl, MD: We are going to talk quickly about psychosis, about half-hour talk

or so, and then we have some questions for my talk and then we will be done for the

day.

Slide 1

To talk about early-onset psychosis, we are going to identify risk factors for getting this

illness and implement treatment interventions for adolescent patients with psychotic

symptoms – not so much children because psychosis in, excuse me, the development

of schizophrenia is thought to be mostly a type of illness that is related to adult

schizophrenia and doesn’t really start in little kids. That’s a di!erent illness. We don’t

really talk much about childhood schizophrenia.

Let’s talk about early-onset psychosis, and basically what is percolating in the brain in

order to develop the whole illness.

Slide 2

Here’s the course of schizophrenia from childhood less than 13 all of the way into

adulthood with four stages often typically put down: premorbid, prodrome, acute, and

chronic. I hope someday before my career gives out to be able to talk about premorbid

both in terms of this illness and in terms of Alzheimer’s disease because once you get

this illness it is not clear that we are really going to be able to modify the course to

bring back normal behavior, but you wonder whether preventing it might actually be

the way to go, so we are looking for genomics in the premorbid period and we don’t

have any.

What you might have is a hint, only in retrospect, the icon for negative symptoms

(empathy – the carrot there is not really a reward, that’s what that is supposed to be)

and the guy with cognitive, no ideas. Cognitive and negative symptoms are there, but,

you know, there’s a lot of people who have those who don’t going get schizophrenia, so

that is so nonspeci”c as to be not useful, so we don’t have a blood test. We don’t have

a brain scan. We don’t have anything – symptom pro”le (if you want to get fancy, you

call that symptom endophenotypes) that would tell us what is going on. We do know

when we look backwards that they probably had negative cognitive symptoms. In fact,

the IQ of schizophrenia patients is at least one standard deviation below normal

compared to the normal population before they even get to the next stage.

Then the famous prodrome – what there is in retrospect, even from World War II, the

idea that during pregnancy if there were infections or malnutrition you might increase

the risk of schizophrenia. There is certainly genetic risk. We don’t know what the genes

are (hypoxia, malnutrition), but in the prodrome you start getting worse in terms of the

negative and cognitive symptoms and a little odd. People are trying to de”ne

symptomatically what they call UHR – ultrahigh risk and try to say, “Okay, these are the

folks who are going to convert, so these are the people who have to jump on and

treat.” There have been some studies of trying to give antipsychotics in this group, but

it has been pretty unremarkable in terms of trying to prevent progress because we

don’t know who is going to convert or who isn’t somebody you know – they didn’t

convert it was because of the drug or just they were going to convert anyway?

What you have here, though, are more symptoms: social withdrawal, academic decline,

your so-called basic symptoms, stress, and drug use, and some people say that then

you start having a little bit of positive if not a lot of positive symptoms, and sometimes

they are called blips and aps. Blips are down there: brief intermittent psychotic

symptoms or attenuated psychosis syndrome. This is before you would say psychotic

break where they are so bad they go in the hospital, but we can all know that we have

seen this.

Not everybody has catastrophic break, but many do, and they convert to God-fearing

or early adulthood may be de”ned as early as 18 or 16 up to age 30 where they start

having these episodic wretched soft tooth thing kind of there before the positive

symptoms and further decline of negative and cognitive symptoms and then sort of a

burnout towards the chronic stage, so we treat people in the acute and chronic and in

this audience if you are involved with early-onset but acute.

One of the things that is interesting about American psychiatry that I have come to try

to understand the di!erence between European and particularly British psychiatry is

they have special clinics for ultrahigh risk patients and for “rst episode and sometimes

they even call it early-onset which might be the “rst episode or two and they are all

separate and they are treated di!erently and they are much more proactive and

aggressive. The other thing that that is accompanied with is something which is sort of

a sad development in the United States which is a lack of really good outpatient care

that can chase people down and give them support which they do have another

countries and a little more paternalistic kind of view where people are nudged a little

bit more into taking treatment even if they don’t want to and the right to refuse

treatment is not quite as strong in those societies. What is happened is that they

prevent some of these awful outcomes.

One of the really amazing and terrible things that is happening in our society by

contrast is that you know that the symptoms of schizophrenia are illegal – against the

law – they are criminal. It’s a crime to have schizophrenia. If you don’t believe me, how

do we treat these patients? As soon and you end up having symptoms, you go to jail,

and so we have criminalized it much more than other societies. We do not focus on

sweet spot if you will.

Now one of the best pieces of news that I have had is been something that has

occurred in California, and I don’t know if it is going to pan out very well, but we have

already found out that in our state (we have 40 million people, okay – I’m the chief

psychiatric consultant for the state hospitals) in the state hospitals in California there

are 7000 patients and 5 facilities, each facility over 1000 people. I have “ve psychiatrists

who work for me full-time in psychopharmacology consults and I go to those hospitals

each a couple of times a year and see some of the worst cases. In our state you have

about 100-110,000 people in jail sitting at one time, 50 percent on psychotropic drugs

and 25 percent of those are psychotic patients. This is about the same proportion in

prisons where there are about 150,000 state prisoners which are people who are

already convicted of a crime and serving more than a year and 7000 in the state

hospitals.

Pop quiz: what does it cost for somebody to be in the state hospital for a year?

$237,000 a year. What does it cost for somebody to be in the state prison in California

in a psychiatric bed is about $200,000 if you are in an acute bed because it’s funny

enough they call it outpatient is when you’re in your cell getting psychiatric care. They

do, and there’s actually some beds for these people, and sometimes they actually

transfer them into our facility for the acute beds, but the outpatients cost about

$100,000-$150,000 a year. What is the cost in jail? About $110,000 a year. So we got an

analysis of this and what this course of treatment is that you only get treatment in the

United States pretty much on the other side of a felony arrest because you have the

right to refuse treatment, and the abuses perhaps that were our fault as a “eld in the

past translated into such a proactive patient’s rights and civil liberties thing the right to

refuse treatment trumps everything and of course people don’t want this illness and

they don’t want their treatment, and the same thing – I don’t know if you have ever

taken care of the bipolar kid schizophrenia kid. It’s really chaotic because when they

are in crisis you can slap them in the hospital and maybe get three days out of it, if you

are lucky, 10. They come out, oh yeah they want to take their medicines, yeah. If they

are staying at home, their mothers can convince them that that runs out after a while

and the kids will open up around the streets and they stop it and until you –

Let me tell you a true story. This is going to be what we are hoping to do for the

outcome four. The state hospitals decided this was such a crazy-assed mess (pardon

my French) that we applied and got (or not going to believe this) a good one $100

million grant from the state of California. Why? Because we calculated that the

treatment of a good outpatient was, with medication – and there’s two things you need

as an outpatient with schizophrenia, and I have never written a prescription for that

but I’m waiting to do it. It is for a house. If you have housing and medicines you are

going to be “ne and you are not going to go to jail or prison, and so what we did was to

say how much is it going to cost to treat a person, and even if you had – because

nobody wants mentally ill patients in their houses in terms of giving them assisted

living or whatever – so you just have to go in and take an apartment building over and

just basically put a little o#ce in there and rent at market rates.

So if you rent at market rates – talking about California – the princes are not cheap. In

LA we’ve got this big program and you put people in that and guess what happens?

You commit a felony, you don’t have any civil liberties anymore, so you can exploit that

to force people to take treatment so you go to them and say, “Look. We have a

diversion program. You want to get treatment, you have to get treatment. You have to

live in this place and you have to take it or you are going to prison, and if you take this

treatment will also drop the charges.”

Well, that’s called leverage, and so what we planned to do is to take people right at the

prodrome in the acute stage is when they have their “rst episode because you know

what happens to the brain? It fries. I was talking to you about that in the “rst lecture.

You talk about DUP – duration of untreated psychosis. It is malignant. The longer you

go the more episodes you have, if you start and stop and start and stop you are

burning the brain up, so by the time you get out there to adulthood you don’t got no

brain no more, so treating at their is not the way to do it, and we are in a criminal

justice system that is actually doing it, so divert people.

You know when you go to the state hospitals? The average person, they come in as ISTs

(incompetent to stand trial) because they are so sick they don’t even know – and they

are getting up charged all the time because the cops know that they go to the

emergency room they are just going to get set out 12 hours so they charged with

felonies even if they are not really felonies, and they have –

Here’s the story I was just trying to think of. My interior decorator just moved recently

(and this is a true story, she decorated the house), she’s a very nice lady who got her

business and does this. I met her husband who is actually the Chief of Pediatric

Neurosurgery for the U.S. Navy (because I live in San Diego), so okay this is a great

family: three sons, #3 is in high school and #2 just started college. Their oldest son

started college, dropped out and had the schizophrenia course or bipolar and they are

not even sure. I haven’t actually seen him myself, so he has been in the hospital. He

takes his drugs, comes out, and relapses. He goes in the hospital, takes his drugs,

relapses.

Now what happens is that one of the times that he took and came out he wanted to go

home, so he’s walking around in the Walmart parking lot. “Will you take me home?”

Well, this guy looks kind of bizarre and young, so “nally after doing for of these he

comes up to a car and says, “Give me your keys” to a lady. She says “I’m not going to

give you my keys.” He says “I’ve got a gun.”

He didn’t have a gun, and the husband of this woman comes out of the time and

chases them down, rests in, and he gets convicted of felony carjacking, sentenced for

three years and goes to jail actually in the prison for a year. Well he’s not a typical

because he’s only at the beginning of his career. The average person comes to the

state hospital for hospitalization has had 14 arrests, is homeless, unmedicated with an

average of 6 months of jail time or arrest so over whatever – 5, 10, 15, 20 years of this

they have had 7 years of which has been in jail. They come in, they get medicated, they

get thrown out. How long does it take you to relapse after you get out of jail? Ten

percent per month, so even if you get loaded up with stu! and get thrown out it takes

you 6 months to have half the people relapse, so they don’t right away and they don’t

commit crimes right away.

Here’s this kid. He does that. He goes to jail. They completely miss the diagnosis. Now

he’s a felon. He gets out and now again he decides to go to Denny’s and doesn’t dine

and dash. Do you know what that is, right? So he eats a $32 meal, gives up to run out of

the place. The store got with the manager is blocking him, the guy hits and, calls the

cops and he hits the cop and he says “cops, I’m going to kill the cop.” Okay, he gets 3

more felonies. What’s that? Assault on the manager of the restaurant, assault on the

cop, and in California we have this thing – I don’t know if you have it in your states –

terrorist threat. If you say “I’m going to kill you, you dirty cop” that’s a terrorist threat,

so they up charged him. This kid is now in jail in San Diego County facing world three

strikes and you’re out in your life without parole for the rest of his life. Okay? You tell

me that that is not one messed up system.

So in September we just passed a law which said that you could have the choice of

diversions. So we are trying to scramble this case that is not well set up yet to try to get

this kid mandatory housing, mandatory treatment so that he doesn’t have this

outcome and isn’t going to spend the rest of his life in prison, so this is one of the

things that we need to think about. Part of my talk is not really where I wanted to go

because we are having to use long-acting injectables, and question someone asked

here in these people, because the hallmark of our diversion program is injectables

because early in the course of illness when this thing starts it’s very easy to treat. It

doesn’t cure them, but I mean they can be very well treatable, and to keep people with

their brains not psychotic they need to have long-acting injectables.

So this is part of the background, and it all starts with pediatric patients. We have an

unusual opportunity to make sure that these people get good treatment, that their

brains are suppressed with the symptoms, that we whenever possible get them out of

the criminal justice system which is where they are going to head for their treatment in

the United States if we are not careful.

Slide 3

You know what the diagnosis is. It’s delusions, hallucinations, you don’t need to know

that. There is also social withdrawal and disorganization. Everybody knows these

diagnostic criteria or you wouldn’t be in the room. It is fairly straightforward.

Schizophrenia is this illness, and it starts in the late teens or early adulthood.

Slide 4

In the pediatric/adolescent presentation it might be a little di!erent than just the

classical paranoid delusions and hallucinations – failure to achieve age-appropriate

levels of functioning. The incidences in the 15-30 range, rare onset before 13, so none

of the drugs are approved for younger than that because they might not even have this

illness very much before that. In this age range particularly 2:1 men.

Slide 5

They have initial trouble telling dreams from reality and seeing things and hearing

voices and the more vivid and bizarre they are the more likely it is to be a problem.

There are actually a lot of mood and anxiety symptoms there. People are out to get

them. They have problems with making and keeping friends. There’s a weird stu! with

their food and eating and of course family history. Obviously, the other thing is there’s

drugs and then after they take a drug or similar drugs and besides drugs – you know,

that’s a di!erent diagnosis is how much of this is drug-induced.

Slide 6

The e!ective management is like we had talked about the whole day today,

psychopharmacology and psychosocial but also as some of the other talks have said

particularly the last one I remember her saying that the psychosocial interventions they

are in bipolar are secondary. They are here, too. I told you this morning that they are

primary in anxiety disorders and they are probably equal in depressive disorders, but

in the other disorders psychopharmacology is probably the hallmark. Antipsychotics

are the mainstay, of course. E#cacy of one is the same as the other, although in

individual patients they can vary and that is the art of psychopharmacology, trying to

“gure out who needs what. One of the biggest problems – all of the medicines work

well – that have the greatest amount of intolerability at this point of the illness, so this

is the trick, to have the art of both e#cacy and safety.

Slide 7

Before starting, of course we have the main problem of weight and metabolic

problems so they have to weigh patients. We have to get baseline history including

their family history of these things, and the one thing I think is not emphasized enough

is the fasting lipid pro”le, and you will see a chart here coming up soon (that’s not it) of

how often you should get fasting lipids. I think that particularly in kids and adults who

are young and adolescence, get a fasting triglyceride because it is a poor man’s or the

poor woman’s insulin resistance treatment. You can show triglycerides going up like

that. You’re talking about days, certainly by the time a couple weeks has gone by you

are going to show that they are going to get a triglyceride response. If they do that,

they are in trouble, so the question is whether you can try to “nd a drug that doesn’t

do that. Not all – clozapine and olanzapine are the biggest sinners. They do the most

but not everybody has that. It is mysterious why it happens, but you can’t do it by

looking at a scale. You’ve got to measure fasting lipid pro”le.

Slide 8

What is approved? Well, the answer is six drugs are approved for psychosis at the ages

of either 12 or 13 as shown here. If you see the little hashmarks, four of them are

approved for acute mania as we heard in the last talk. In fact, as you know olanzapine

with $uoxetine and lurasidone (not shown here with crosses) are approved for bipolar

depression as well, and some of them with little stars are approved for autism-related

irritability. I’m not so sure as a psychopharmacology is, the reason that all of the drugs

are not approved for all of the things is because they don’t work on those things. I

think that there are commercial reasons that people don’t test that and there’s weird

stu! that makes placebo response high in some trials, and if you don’t keep doing it

over and over again you don’t prove the drug works. To me, I really believe that this is a

class e!ect and that the absence of evidence is not necessarily evidence of absence,

but this is what you want to do and you have to work in the real world, so knowing this

covers your tush. Start with drugs that are approved for this just because it’s easier on

you and the parents and getting second-guessed. Eventually, I think all drugs are

probably the same except that – has anybody in this room ever treated somebody with

one of these drugs or one of any drugs of this class, adult or child, and it didn’t work

and you give them another one and it did. No, that’s not the case, they are all the

same. As anybody in this room ever treated somebody with one of these drugs and

had a side e!ect and you changed to another one and they didn’t have it? No, that

can’t happen. There’s a di!erence between being too scienti”c and having some

common sense. But you have to play the game and the game starts with where the

best evidence is.

Slide 9

Here’s the aripiprazole one. You don’t need to have rocket science to “gure out that

those line separate and that at 10 and 20 were the doses and 30, 30 works better than

10. That seems to be a halva dose. I don’t always use that high, but that is what the

data shows.

Slide 10

If you want to look at lurasidone, this is a cool one – 40 and 80. One thing that is

interesting, pop quiz: what does lurasidone do in kids who don’t have a lot of

experience taking antipsychotic drugs and what does also aripiprazole do? It makes

you throw up. Isn’t that weird? They don’t like the 5H21A properties, and where do you

see that in adults? You see that in adults with bipolar depression who aren’t used to

taking antipsychotics, and you whack them with this drug or aripiprazole at 10

milligrams or this drug at 40 and you will get vomiting in that group, too. The reason

you don’t get it in adults with these disorders is because they have a career of being on

drugs in this class so they are kind of desensitized to it, so be alert to the fact that a lot

of adolescents who have never been treated before in these drugs just because they

make you throw up doesn’t mean they don’t work, but if you get somebody throwing

up and they don’t want to take it anymore there are perfectly great drugs that you

blow because the person says “I threw up and I never want to take it again, so be

careful on titrating.

Slide 11

Olanzapine works, but it kills you – not kills you, but we use a lot of olanzapine in the

state hospitals because the patients are so sick, they are so violent, they are felons,

they are hitting each other in the rooms, they are hitting the sta!. Pop quiz: what do

we do in the state hospitals and what I would say you should do when there’s no real

good evidence for this one, I’m going to tell you that anyway because I’m a real doctor

and I’m trying to help you, what do I do with everybody I start on olanzapine today?

Metformin, exactly. Why? Because Metformin helps you prevent weight gain more than

it helps you lose weight, and if you are going to have to use olanzapine it’s a perfectly

great drug – clozapine, yeah, but wait until they gained 50 pounds or 20 pounds? I don’t

think so. This is a great drug, it works terri”c. It’s probably better than the other ones,

although there are no head-to-head studies to prove that, so we use this for test cases

but we try to not kill them, the particularly young kids.

Slide 12

Paliperidone is an interesting drug. It seems to work in this better at the medium dose

than at the high dose, maybe the high doses just giving you side e!ects so in this

particular case medium dose was better.

Slide 13

They did it against aripiprazole and the two look to the same on the outcomes, but just

what? They just had di!erent side e!ects. Oh yeah? No duh! With paliperidone there

was akathisia, headaches. They didn’t say here but they have the hyperprolactinemia

and with aripiprazole there was worsening of schizophrenia which means it didn’t work

quite as well. There is some question whether aripiprazole is one of the better

tolerated drugs but maybe not, the most e#cacious, who knows if that’s true or not? I

think it is plenty e#cacious in the adolescent group for almost everybody because they

don’t need the olanzapine, clozapine bang between your eyes drugs yet.

Slide 14

What about aripiprazole versus paliperidone? There’s really no di!erence in e#cacy in

the study nor in any other ones; however, I have had aripiprazole responders that

aren’t paliperidone and the other way around. I’m a real doctor. This does not – you

know what this is called? It’s the tyranny of the median patient, the tyranny! I don’t

treat median patients. I treat you and I treat you, and what I love to do is to live for the

outlier because I’m a little bit naīve. I’m hoping you get a better response than you

should. The median response is terrible for your illness, but Johnny little optimistic

crazy guy says ‘Oh, but may be you will be the one that is really that awakening that

you see with clozapine, I want that. And maybe you will be the one who has the really

great tolerability. Oh, yeah, you’re the olanzapine person who doesn’t gain weight.’

Slide 15

In this case, risperidone didn’t work any di!erent than the two doses.

Slide 16

Long-term risperidone studies, I mean, you don’t need to look at this to know what I’m

talking about.

Slide 17

Now here’s the LAIs. They are not approved as our previous speaker told you, but I

think they should be used, and the older you are, I mean, what’s the di!erence. I mean

if you are 16 or a 15-year-old going on trial for murder as an adult, I think we could use

the damn LAI as an adult, too. So we do that. I mean, you should probably be 100

pounds and nobody really knows how to adjust these doses down, but usually before

you are an adolescent you have this thing which is a highly technical and amazing

product that gives you compliance. It’s called a mother. Then you lose your mother and

you lose your compliance and you go to a long-acting injectable, right?

Slide 18

Treatment resistance can be treated with clozapine. There are not a lot of studies. It is

not approved, but I have used it. In fact, one of the things that has been the most

interesting cases was two physicians, one of whom was a psychiatrist and one was a

very well-known person both at UCLA who came to me with a child with ultra-high risk

of schizophrenia and they insisted I put their son on clozapine and he didn’t have

schizophrenia yet, because they had read about it and they understood how

devastating this illness was and they were hoping – I did it, but I’m not sure it was the

right thing to do, but the idea is that clozapine has something di!erent about it and I

don’t use it as “rst-line. Even though that is what I did. They didn’t have schizophrenia

yet, but sometimes you have to do what you have to do. It does cause a lot of

metabolic problems, so the risk/bene”t ratio has got to be calculated by you, but that is

why they pay you the big bucks to “gure that out.

Slide 19

For second line use, use clozapine. The other things that we do in adults are not used

so much until you get closer to adult range. What we do in high dosing and

polypharmacy and plasma drug levels, but I see the sickest schizophrenics in the world.

In 2011 I took a job at the state hospitals and I thought I already knew some

psychopharmacology. I had even written a couple of books by then, but when I went to

the state hospital it was like I was in my residency all over again. These patients were

unbelievable – does anybody work at a state hospital? Oh my God, I take my hat o! to

you, at a forensic facility these are amazing cases. So some of the things that you do

that are evidence-based, nobody would ever take forensic patients – it’s unethical to do

double-blind trials of placebo-controlled, get out of here. They would never be studied,

so they are all done by experience, and one of the things we do is hire dosing and

polypharmacy and plasma levels for those patients, but you can also use clozapine, but

just to be complete haloperidol is approved in children for Tourette’s and psychosis.

Chlorpromazine is weird. I dare you to read what it is approved for. It will make you

shudder. It is basically saying if you misbehave give them chlorpromazine. It is

amazing. You would never get it approved for that today. It is almost abusive, but it’s

got at least some safety data, and pimozide for Tourette’s. Of course, that will kill you

with QTC, but that’s not a real problem. So I wouldn’t do these things. I give it to you

because I want you to know that there is safety data in children with these drugs, but

on e#cacy I would much rather use high-dosing polypharmacy guided by or clozapine

guided by levels.

Slide 20

Here’s a couple of failed trials. Does that mean these are crappy drugs or does that

mean they were crappy studies? I think it is more likely these were crappy studies and

bad luck, but be aware that these are not approved. Ziprasidone is probably not the

world’s greatest drug anyway. Asenapine is really cool because it’s like a p.r.n. without

a needle. There’s two ways in even talk about that. One of the things we are going to

do is equip our outpatient forensics with two weapons; one is sublingual asenapine. If

you take the asenapine that is in that little wafer kind of thing, it’s the same kind of

thing that Zyprexa is in, but Zyprexa is basically fake because when you take Zyprexa it

feels like it has gone really fast, but you are swallowing it and the saliva is sliding down

your esophagus and if you look at the plasma drug levels it is the same as if you took a

pill, and so the C max is like 90 minutes. If you take one of the asenapine it is in there

like, boom, 20 minutes. The other one is inhaled loxapine. Now that obviously has

gotten some REMs with it and some pain to use, but if you need to have a p.r.n.

without a needle you’ve got two choices and those are things you might need in a kid, a

mother might need that to keep her from or a school nurse, so those are two tips but

that is complete – okay, it’s getting late in the day. And I’m weakening. I didn’t know I

was going to do this, but not only have I gone o! label I have gone wildly o! label for

you here, but that, sometimes you need some tips.

Slide 21

Side e!ects, children are even more vulnerable for all of these famous side e!ects you

know so well in adults, and we have to be careful more in kids than in adults even.

Slide 22

Monitoring people is the same baseline lab work. You see all of this stu!, physical,

maybe one cardiogram, but the idea is to get fasting lipids. I think the next slide is

going to show that. Yeah, here it is.

Slide 23

This is a famous paper, there’s a consensus. I don’t think these people see patients

because the reality is that do you see the fasting lipid at the bottom? When this

originally came out it was annual. They put an X under 12 weeks. When I am changing

you from drug A to drug B, and I don’t care if you are an adult or child. I don’t care if it

is bipolar depression, if you are given an atypical antipsychotic you are getting a

baseline fasting triglycerides before I give you the drug and then I’m going to give you a

prescription for the drug and a prescription for another fasting triglyceride and I want

you to get the fasting triglyceride and I want it back on my chart so I can see it when

you come in again so that it is basically at 4 weeks usually I see patients. They come in

at 3 weeks, the lab gets it, they come back, and then I’m going to know. If you have

popped your triglycerides up we are going to have to have a conversation, and the

same thing happens if I switch you. I get them every month until you are stable, and

then if you switch from a drug that caused triglycerides to go up, a drug that doesn’t

cause triglycerides to go up, guess what? It will go down as fast as it went up. Pop quiz:

What are the worst ones that make it go up? Clozapine and olanzapine. What are the

ones that don’t make it go up at all? Well, you never say never but there are a couple

that are almost never. What are those two? Cariprazine and lurasidone, and what are

the ones that are pretty good in most people but not perfect? Brexpiprazole and

aripiprazole, and then the rest of them are kind of in the middle.

Slide 24

Summary: early identi”cation and treatment can limit functional loss and

schizophrenia; antipsychotic treatment should be dosed low; “rst-episode patients are

more sensitive to side e!ects; and onset of psychosis completely upends the lives of

individuals who are transitioning into adulthood – psychosocial strategies and support

are essential.

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