Psychopharmacology and Psychiatry Updates Choosing First-Line Antipsychotics: Considering Violence
Nov 17, 2025
Join psychiatrist Oliver Freudenreich from Harvard Medical School as he dives into an innovative Mayo Clinic algorithm for selecting antipsychotics for first-episode psychosis. He discusses how the presence of violence influences the choice of medication, recommending options like aripiprazole and olanzapine. He emphasizes the effectiveness and adherence benefits of long-acting injectables and defends olanzapine’s use despite its metabolic risks. The conversation culminates in a practical application of these insights to real cases.
AI Snips
Chapters
Transcript
Episode notes
Marcus: A Typical First-Episode Vignette
- Marcus, a 19-year-old college student, presents with three weeks of paranoia, stopped classes, and agitation after a roommate suggested help.
- This vignette frames the clinical question of which antipsychotic to choose for first-episode psychosis.
Violence As The Key Decision Point
- The Mayo Clinic algorithm stratifies first-episode antipsychotic choice primarily by presence or absence of violence.
- That single decision point then directs markedly different first-line medication pathways and escalation strategies.
Reconsidering Olanzapine's Role
- The algorithm includes olanzapine among four first-line options despite its metabolic risks.
- Long-term data suggest olanzapine's strong efficacy may lead to better adherence and comparable mortality outcomes versus other agents.