Atypical antipsychotic medication in the treatment of first episode schizophrenia

Clozapine, an atypical antipsychotic medication that rarely causes tardive dyskinesia (TD) or extrapyramidal symptoms (EPS), has been demonstrated to reduce psychopathology in up to 60% of severely ill schizophrenic patients who had failed to respond to conventional neuroleptics. Clozapine, however, can induce agranulocytosis in 1% of patients and its use requires patients to have regular hematologic monitoring. Clozapine is currently indicated only for treatment resistant schizophrenia and for psychotic patients with severe TD or EPS, and therefore not a first line treatment for schizophrenia. Nevertheless, an important question is whether clozapine might be a more effective treatment in nonrefractory patients particularly if used at the first treatment exposure. In order to assess the efficacy and safety of clozapine as a first line treatment for schizophrenia we have administered clozapine to 14 neuroleptic naive RDC schizophrenic patients participating in a prospective study of the psychobiology of first episode schizophrenia. Of the 14 patients, one had his clozapine stopped due to neutropenia. Eight of the remaining 13 patients have received at least three months of treatment, with six of the eight having met remission criteria. The prevalence and severity of side effects including fever, tachycardia, hypotension, weight gain and sedation, were greater than rates that have been reported in chronic patient samples. These data along with the results obtained from the use of risperidone and conventional antipsychotics in the treatment of first episode schizophrenic patients will be discussed.