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A 20-year-old woman was referred by her family physician to a community mental health team in London, United Kingdom. Her mental state had deteriorated progressively over the previous 12 months, following the death of her father. After a period living alone, she had returned to the family home 4 months prior to her presentation and had been noted to be socially withdrawn, preoccupied, and distractible. Her family physician, suspecting a depressive episode, had prescribed citalopram up to a dosage of 40 mg once daily, to no effect. Her family subsequently sought advice from the family physician when the patient was noted to be speaking to herself, expressing concerns about people meaning her harm, and professing the belief that she could hear other peoples’ thoughts.
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A. Consider the risk of adverse events and which drugs are approved for use
There are no clear differences in efficacy between licensed antipsychotic medications in head-to-head trials, although network meta-analyses1,2 suggest that clozapine, olanzapine, and amisulpride are among the most efficacious. Note: Amisulpride is approved for use in the United Kingdom where this patient was treated but is not approved for use in the United States. In addition to the short-term efficacy of antipsychotic medication, there is also evidence that maintenance treatment with antipsychotic drugs lowers the risk of relapse.3
In addition to efficacy, the risk of adverse effects should be carefully considered when discussing treatment options (choice A). The patient in this clinical challenge is of African origin and had overweight, both of which increase the likelihood of adverse metabolic effects developing during antipsychotic treatment.4 Furthermore, psychosis itself is associated with an increased risk of metabolic dysfunction.5 Consequently, if efficacy and other risks of adverse effects are equal, treatments with a high risk of adverse metabolic effects, such as olanzapine (choice B), should be avoided if possible. Alternatives to amisulpride with relatively low levels of adverse metabolic effects include haloperidol and aripiprazole.
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Corresponding Author: Oliver D. Howes, MD, PhD, Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, Kings College London, De Crespigny Park, PO Box 67, London SE5 8AF, United Kingdom (email@example.com).
Published Online: October 30, 2019. doi:10.1001/jamapsychiatry.2019.3369
Correction: This article was corrected on January 15, 2020, to fix a quiz answer and text in the Discussion and Patient Outcome sections.
Conflict of Interest Disclosures: Dr Reis Marques reported personal fees from Lundbeck, Janssen, Astellas, and Angelini and grants from Medical Research Council of the United Kingdom during the conduct of the study. Dr Howes reported grants, personal fees, and nonfinancial support from Angelini, AstraZeneca, Autifony, Biogen, Eli Lilly, Heptares, Janssen, Lundbeck, Lyden-Delta, Otsuka, Sunovion, Rand, Recordati, and Roche outside the submitted work. No other disclosures were reported.
Additional Contributions: We thank the patient for granting permission to publish this information.
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