Patient handout

First-Episode Psychosis (FEP) — medical workup + low-dose antipsychotic + CSC (APA 2024; RAISE-ETP Kane AJP 2016)

PRODUCTION

1. Your condition

This handout is for first-episode psychosis (fep) — medical workup + low-dose antipsychotic + csc (apa 2024; raise-etp kane ajp 2016). Your care team identified this based on: new-onset hallucinations, delusions, or disorganised thinking/behaviour without prior psychotic episode (dsm-5-tr 2022; apa 2024).

Other reasons your team may use this plan: acute agitation with psychotic features — first presentation (apa 2024; nice 2024); attenuated psychosis syndrome / clinical high-risk state progressing to full psychosis (dsm-5-tr 2022; yung aust n z j psychiatry 2005); family / collateral report of bizarre behaviour, social withdrawal, functional decline over weeks-months (apa 2024; nice 2024).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
aripiprazole	5–10 mg PO daily	PO	once daily	APA 2024 / PORT (Buchanan Schizophr Bull 2010) — lowest metabolic burden; partial D2 agonist reduces EPS and prolactin elevation; Leucht Lancet 2013 network meta-analysis supports efficacy
risperidone	1 mg PO daily	PO	once daily or BID	APA 2024 / PORT (Buchanan Schizophr Bull 2010) — effective for positive symptoms; dose-dependent EPS and prolactin; lower doses in FEP than chronic; Leucht Lancet 2013

Plan: FEP antipsychotic ladder — aripiprazole → risperidone → olanzapine → clozapine (treatment-resistant) + LAI early (APA 2024; PORT Buchanan Schizophr Bull 2010; Leucht Lancet 2013)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Doing well — symptoms controlled, functioning improving, medication adherent (APA 2024; NAVIGATE Robinson NEJM 2015)

If you have:

No hallucinations or delusions (APA 2024)
Sleeping and eating normally (APA 2024)
Attending appointments, school, or work (RAISE-ETP Kane AJP 2016)
Taking medications as prescribed (APA 2024)
Not using substances (APA 2024; NICE 2024)
Engaging with family and supports (RAISE-ETP Kane AJP 2016)

Do this:

Take antipsychotic every day as prescribed — do not stop without discussing with your CSC team (APA 2024)
Attend all CSC appointments — prescriber, therapist, case manager (RAISE-ETP Kane AJP 2016)
Continue CBTp skills practice (NICE 2024)
Avoid cannabis, alcohol, and other substances — these can trigger relapse (APA 2024)
Maintain regular sleep schedule and daily routine (APA 2024; NICE 2024)
Keep crisis line numbers accessible (APA 2024)

YELLOW — Caution — early warning signs of relapse, stress, or adherence lapse (APA 2024; NICE 2024)

If you have:

Difficulty sleeping or sleeping too much (APA 2024; DSM-5-TR 2022)
Feeling suspicious or paranoid but not certain (APA 2024)
Hearing faint sounds or voices that are not clear (APA 2024)
Difficulty concentrating, feeling confused (APA 2024)
Increased anxiety or irritability (APA 2024)
Social withdrawal — avoiding people or appointments (APA 2024; RAISE-ETP Kane AJP 2016)
Missed medication doses in the past week (APA 2024)
Using cannabis, alcohol, or other substances again (APA 2024)

Do this:

Contact your CSC team or prescriber within 24–48 h — do not wait for your next scheduled appointment (RAISE-ETP Kane AJP 2016; APA 2024)
Resume medication if you have missed doses (APA 2024)
Use CBTp coping strategies — reality testing, grounding techniques (NICE 2024)
Reach out to a support person or family member (RAISE-ETP Kane AJP 2016)
Avoid all substances including cannabis (APA 2024)
Increase structure — follow daily routine, attend peer support (APA 2024; RAISE-ETP Kane AJP 2016)

Call your provider if:

Any warning sign persists >2 days despite coping strategies (APA 2024)
Hearing voices more clearly or more often (APA 2024)
Feeling unable to tell what is real (APA 2024)
Thoughts of hurting yourself or others (APA 2024; Palmer Arch Gen Psychiatry 2005)
Stopped taking medication for ≥3 days (APA 2024)

RED — Medical alert — acute psychosis, command hallucinations, suicidality, catatonia, NMS signs (APA 2024)

If you have:

Clear voices commanding you to harm yourself or others (APA 2024)
Strong belief that people are trying to hurt you or control you (APA 2024)
Unable to tell what is real (APA 2024)
Thoughts or plans to end your life (APA 2024; Palmer Arch Gen Psychiatry 2005)
Not moving, speaking, or eating for hours — catatonia signs (APA 2024)
Very high fever + severe muscle stiffness after taking antipsychotic — possible NMS (APA 2024)
Severe agitation, aggression, or self-harm (APA 2024)

Do this:

Call 988 (US) / your local crisis line / emergency services NOW (APA 2024)
Go to the nearest emergency department — do not be alone (APA 2024)
Tell someone you trust what is happening immediately (APA 2024; RAISE-ETP Kane AJP 2016)
If fever + stiff muscles after antipsychotic — go to ED immediately (possible NMS per APA 2024)
Do not take more medication than prescribed (APA 2024)
Do not use any substances (APA 2024)

Call your provider if:

Any red zone trigger — emergency department immediately (APA 2024)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Severe psychomotor agitation with psychotic features — unable to de-escalate verbally (APA 2024; Wilson Psych Serv 2012 Project BETA)
Active suicidal ideation with intent or plan, or recent self-harm in FEP patient (C-SSRS positive; Palmer Arch Gen Psychiatry 2005)(life-threatening)
Command auditory hallucinations directing harm to self or others with perceived inability to resist (APA 2024; DSM-5-TR 2022)(life-threatening)
Catatonia signs: immobility, mutism, posturing, waxy flexibility, negativism, staring — Bush-Francis ≥2 features (APA 2024; NICE 2024)
Hyperthermia >38C, lead-pipe rigidity, altered consciousness, autonomic instability, CK elevation after antipsychotic exposure — Levenson criteria (APA 2024)(life-threatening)
Subacute behavioural change (< 3 months) + ≥ 1 of (seizures / orofacial dyskinesia / autonomic instability / decreased consciousness / cognitive decline) + ≥ 1 supporting feature (CSF lymphocytic pleocytosis OR EEG abnormality OR MRI T2/FLAIR abnormality) + young patient (especially female; ovarian teratoma 11-36% paediatric / 58% adult-female cases) — possible / probable autoimmune encephalitis per Graus Lancet Neurol 2016 criteria (Dalmau Lancet Neurol 2011 PMID 21163445; Pollak Lancet Psychiatry 2020 PMID 32078818)
Psychotic symptoms persisting > 1 month after documented cessation of cannabis / methamphetamine / PCP / synthetic cannabinoid / LSD / other substance — fails the DSM-5-TR 2022 substance-induced psychotic disorder timeline (typically resolves within days-weeks of substance clearance) (DSM-5-TR 2022; APA 2024)
Failure of ≥ 2 adequate antipsychotic trials at adequate dose × 4-6 weeks each — treatment-resistant schizophrenia (TRS) per APA 2020 / NICE CG185 2024 / PORT Buchanan Schizophr Bull 2010 PMID 20513679

5. Follow-up

Continue antipsychotic ≥1–2 years after remission of first episode (APA 2024; PORT Buchanan Schizophr Bull 2010); CSC program ≥2 years (RAISE-ETP Kane AJP 2016; NAVIGATE Robinson NEJM 2015); relapse prevention — medication adherence, substance avoidance, stress management, family involvement; consider LAI if adherence concerns; supported employment/education ongoing (APA 2024; NICE 2024)

6. Sources

Guideline: APA Practice Guideline for Schizophrenia 2024 + PORT (Buchanan Schizophr Bull 2010) + RAISE-ETP (Kane AJP 2016) + NAVIGATE (Robinson NEJM 2015) + NICE CG185 2024 + Leucht Lancet 2013