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psych.first-episode-psychosis.core.v1PRODUCTION
psych.first-episode-psychosis.core.v1

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

psychiatryacutechronicadult
Hard-required inputs
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm first psychotic episode in adult ≥16 — no prior documented psychotic episode; duration ≥1 day of frank psychosis (DSM-5-TR 2022 schizophreniform / brief psychotic / schizophrenia spectrum; APA 2024)

Inputs
0
Actions
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Advance rule
Set
Advance when

First-episode status confirmed and organic mimics not yet excluded (APA 2024)

Patient inputs (24)

Age at onset informs differential — FEP peak 18–25; late onset >40 raises concern for organic cause (APA 2024; DSM-5-TR 2022)

Sex-specific metabolic monitoring; prolactin effects of antipsychotics (APA 2024; Leucht Lancet 2013)

DUP predicts outcome — shorter DUP → better prognosis; target <3 months (Robinson NEJM 2015; RAISE-ETP Kane AJP 2016)

UDS mandatory — cannabis, methamphetamine, PCP, synthetic cannabinoids, LSD can cause or precipitate psychosis; distinguish substance-induced vs primary (APA 2024; DSM-5-TR 2022)

Rule out organic psychosis: autoimmune encephalitis (anti-NMDAR), CNS infections, metabolic, endocrine, neurological (APA 2024; Pollak Lancet Psychiatry 2020)

Schizophrenia heritability ~80%; first-degree relative with psychotic disorder increases pretest probability (Sullivan Am J Psychiatry 2012; APA 2024)

Drug-induced psychosis screen: steroids, dopamine agonists, anticholinergics, stimulants; medication interactions with antipsychotics (APA 2024)

Urine drug screen mandatory — exclude substance-induced psychosis (APA 2024; DSM-5-TR 2022)

Thyroid dysfunction mimics psychosis — baseline TSH mandatory (APA 2024)

B12 deficiency can cause psychosis; check in FEP workup (APA 2024; NICE 2024)

HIV encephalopathy can present as psychosis; screen at FEP (APA 2024; NICE 2024)

Neurosyphilis can present as psychosis; RPR/VDRL screening (APA 2024; NICE 2024)

Baseline CBC; required for clozapine monitoring if escalated (APA 2024; Leucht Lancet 2013)

Electrolytes, renal function baseline before antipsychotic start (APA 2024)

Metabolic baseline before atypical antipsychotic — weight gain, diabetes risk (APA/ADA 2004 consensus; APA 2024)

Lipid panel baseline for metabolic monitoring on atypical antipsychotics (APA/ADA 2004 consensus; APA 2024)

MRI brain to exclude structural lesion, demyelination, or encephalitis in FEP — recommended for all first episodes (APA 2024; NICE 2024)

ECG baseline — QTc assessment before antipsychotic; ziprasidone, haloperidol IV carry QTc risk (APA 2024; FDA)

Suicide risk elevated 5–10% lifetime in FEP; C-SSRS at every visit (Palmer Arch Gen Psychiatry 2005; APA 2024)

PANSS or BPRS to quantify positive/negative/general symptom burden at baseline and track response (APA 2024; PORT Buchanan Schizophr Bull 2010)

Anti-NMDA receptor antibodies if clinical suspicion for autoimmune encephalitis — young female, seizures, dyskinesias, autonomic instability (Pollak Lancet Psychiatry 2020; APA 2024)

Premorbid IQ, social/occupational function, and academic trajectory inform prognosis and CSC treatment targets (RAISE-ETP Kane AJP 2016; NAVIGATE Robinson NEJM 2015)

Hepatic function baseline; hepatically metabolised antipsychotics (APA 2024)

Baseline prolactin before antipsychotic — risperidone/paliperidone high prolactin risk (APA 2024; Leucht Lancet 2013)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement
  • informationallife_threateningself_harm_or_suicidal_ideation_fep (Palmer Arch Gen Psychiatry 2005; APA 2024)
    Active suicidal ideation with intent or plan, or recent self-harm in FEP patient (C-SSRS positive; Palmer Arch Gen Psychiatry 2005)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningcommand_hallucinations_to_harm (APA 2024)
    Command auditory hallucinations directing harm to self or others with perceived inability to resist (APA 2024; DSM-5-TR 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningnms_neuroleptic_malignant_syndrome (APA 2024)
    Hyperthermia >38C, lead-pipe rigidity, altered consciousness, autonomic instability, CK elevation after antipsychotic exposure — Levenson criteria (APA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereacute_agitation_psychotic (APA 2024)
    Severe psychomotor agitation with psychotic features — unable to de-escalate verbally (APA 2024; Wilson Psych Serv 2012 Project BETA)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecatatonia_in_fep (APA 2024; NICE 2024)
    Catatonia signs: immobility, mutism, posturing, waxy flexibility, negativism, staring — Bush-Francis ≥2 features (APA 2024; NICE 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereautoimmune_encephalitis_features
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresubstance_induced_psychosis_not_resolving
    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)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveretreatment_resistant_psychosis
    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
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatemetabolic_syndrome_on_antipsychotic (APA/ADA 2004; APA 2024)
    New-onset metabolic syndrome: weight gain >7% baseline, fasting glucose ≥126, A1c ≥6.5%, triglycerides ≥150, waist circumference increased on atypical antipsychotic (APA/ADA 2004 consensus; APA 2024)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

FEP antipsychotic ladder — aripiprazole → risperidone → olanzapine → clozapine (treatment-resistant) + LAI early (APA 2024; PORT Buchanan Schizophr Bull 2010; Leucht Lancet 2013)
axis: fep_antipsychotic_ladderstep 1 - Step 1 — Low-dose aripiprazole or risperidone first-line (APA 2024; PORT Buchanan Schizophr Bull 2010; Leucht Lancet 2013)
Selected step "Step 1 — Low-dose aripiprazole or risperidone first-line (APA 2024; PORT Buchanan Schizophr Bull 2010; Leucht Lancet 2013)" — First-episode psychosis, no prior antipsychotic exposure, no contraindication (APA 2024; PORT Buchanan Schizophr Bull 2010)
  • aripiprazole
    first line
    atypical_antipsychotic
    5–10 mg PO daily • PO • once daily (max: 15–20 mg/day in FEP (lower than chronic schizophrenia per Leucht Lancet 2013))
    triggers: fep_first_line, metabolic_risk_concern, prolactin_concern
    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
    rxcui 89013
  • risperidone
    first line
    atypical_antipsychotic
    1 mg PO daily • PO • once daily or BID (max: 3–4 mg/day in FEP (PORT Buchanan Schizophr Bull 2010))
    triggers: fep_first_line, positive_symptom_predominant
    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
    rxcui 35636

outpatient playbook — drug actions (4)

  1. 1. continue or optimise oral antipsychotic from inpatient
    Aripiprazole 10–15 mg PO daily or risperidone 2–3 mg PO daily • PO • daily
    trigger: Outpatient CSC entry, stabilised on oral antipsychotic (APA 2024; PORT Buchanan Schizophr Bull 2010)
    APA 2024 / PORT (Buchanan Schizophr Bull 2010) — continue effective dose; lowest effective dose in FEP; Leucht Lancet 2013
  2. 2. offer LAI transition if adherence concern or patient preference
    Aripiprazole Maintena 400 mg IM monthly or paliperidone palmitate per schedule • IM • monthly
    trigger: Missed doses, non-adherence identified, patient preference (APA 2024; Subotnik AJP 2015)
    APA 2024 — early LAI in FEP reduces relapse; Subotnik AJP 2015 randomised FEP LAI trial showed 73% lower relapse vs oral
  3. 3. switch antipsychotic if side effects or inadequate response
    Cross-titrate per APA 2024 switching guidelines; see Step 2 in regimen_axes • PO • daily
    trigger: Metabolic side effects, EPS, prolactin symptoms, or residual positive symptoms (APA 2024; Leucht Lancet 2013)
    APA 2024 / Leucht Lancet 2013 — choose based on side-effect profile vs efficacy trade-off
  4. 4. clozapine if treatment-resistant (failed ≥2 adequate trials)
    Clozapine 12.5 mg → titrate slowly; target trough 350–600 ng/mL • PO • BID to TID
    trigger: Treatment-resistant psychosis per PORT criteria (Buchanan Schizophr Bull 2010; APA 2024; NICE 2024)
    APA 2024 / PORT (Buchanan Schizophr Bull 2010) / NICE 2024 — do not delay clozapine if treatment-resistant criteria met; only agent with proven superiority in TRS; REMS ANC monitoring required

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: New-onset hallucinations, delusions, or disorganised thinking/behaviour without prior psychotic episode (DSM-5-TR 2022; APA 2024); 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).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**First-Episode Psychosis (FEP) — medical workup + low-dose antipsychotic + CSC (APA 2024; RAISE-ETP Kane AJP 2016)** (psych.first-episode-psychosis.core.v1).
Phenotype framing: Schizophrenia vs schizophreniform vs brief psychotic disorder vs substance-induced psychotic disorder vs psychotic disorder due to another medical condition vs delusional disorder vs mood disorder with psychotic features vs autoimmune encephalitis vs CNS infection (DSM-5-TR 2022; APA 2024)
Scope: Confirm first psychotic episode in adult ≥16 — no prior documented psychotic episode; duration ≥1 day of frank psychosis (DSM-5-TR 2022 schizophreniform / brief psychotic / schizophrenia spectrum; APA 2024)

No severity triggers fired against current inputs.

Plan

Regimen axis: **FEP antipsychotic ladder — aripiprazole → risperidone → olanzapine → clozapine (treatment-resistant) + LAI early (APA 2024; PORT Buchanan Schizophr Bull 2010; Leucht Lancet 2013)** — step "Step 1 — Low-dose aripiprazole or risperidone first-line (APA 2024; PORT Buchanan Schizophr Bull 2010; Leucht Lancet 2013)".
1. aripiprazole 5–10 mg PO daily PO once daily (atypical_antipsychotic, first line) — 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
2. risperidone 1 mg PO daily PO once daily or BID (atypical_antipsychotic, first line) — 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

Setting playbook (outpatient) — Coordinated specialty care (CSC) — sustained antipsychotic optimisation, CBTp, family psychoeducation, supported employment/education, substance use treatment, relapse prevention (RAISE-ETP Kane AJP 2016; NAVIGATE Robinson NEJM 2015; APA 2024)
3. continue or optimise oral antipsychotic from inpatient Aripiprazole 10–15 mg PO daily or risperidone 2–3 mg PO daily PO daily — Outpatient CSC entry, stabilised on oral antipsychotic (APA 2024; PORT Buchanan Schizophr Bull 2010) (APA 2024 / PORT (Buchanan Schizophr Bull 2010) — continue effective dose; lowest effective dose in FEP; Leucht Lancet 2013)
4. offer LAI transition if adherence concern or patient preference Aripiprazole Maintena 400 mg IM monthly or paliperidone palmitate per schedule IM monthly — Missed doses, non-adherence identified, patient preference (APA 2024; Subotnik AJP 2015) (APA 2024 — early LAI in FEP reduces relapse; Subotnik AJP 2015 randomised FEP LAI trial showed 73% lower relapse vs oral)
5. switch antipsychotic if side effects or inadequate response Cross-titrate per APA 2024 switching guidelines; see Step 2 in regimen_axes PO daily — Metabolic side effects, EPS, prolactin symptoms, or residual positive symptoms (APA 2024; Leucht Lancet 2013) (APA 2024 / Leucht Lancet 2013 — choose based on side-effect profile vs efficacy trade-off)
6. clozapine if treatment-resistant (failed ≥2 adequate trials) Clozapine 12.5 mg → titrate slowly; target trough 350–600 ng/mL PO BID to TID — Treatment-resistant psychosis per PORT criteria (Buchanan Schizophr Bull 2010; APA 2024; NICE 2024) (APA 2024 / PORT (Buchanan Schizophr Bull 2010) / NICE 2024 — do not delay clozapine if treatment-resistant criteria met; only agent with proven superiority in TRS; REMS ANC monitoring required)

Non-pharmacologic actions:
- CBT for psychosis (CBTp) — weekly sessions per NICE 2024; NAVIGATE Individual Resiliency Training (Robinson NEJM 2015)
- Family psychoeducation and intervention — RAISE-ETP (Kane AJP 2016); Family-aided Assertive Community Treatment
- Supported employment and education — IPS model per RAISE-ETP (Kane AJP 2016); NAVIGATE (Robinson NEJM 2015)
- Substance use treatment — motivational interviewing, CBT for SUD, consider naltrexone for AUD (APA 2024; NICE 2024)
- Social skills training (APA 2024; NICE 2024)
- Case management and care coordination — CSC team model (RAISE-ETP Kane AJP 2016)
- Lifestyle counselling: exercise, diet, sleep hygiene, smoking cessation (APA 2024; NICE 2024)
- Peer support integration (RAISE-ETP Kane AJP 2016)

AVOID / contraindication checks:
- Clozapine_ANC_below_1500_do_not_initiate (APA 2024; clozapine REMS)
- Clozapine_ANC_below_1000_hold_and_monitor (APA 2024; clozapine REMS)
- QTc_prolongation_avoid_ziprasidone_haloperidol_IV_if_QTc_above_500ms (APA 2024; FDA)
- NMS_discontinue_all_antipsychotics_supportive_care_dantrolene (APA 2024)
- Olanzapine_IM_plus_benzodiazepine_avoid_respiratory_depression (FDA 2004; APA 2024)
- Antipsychotic_avoid_in_confirmed_substance_induced_psychosis_if_resolving (DSM 5 TR 2022; APA 2024)
- Metabolic_syndrome_monitoring_mandatory_all_atypical_antipsychotics (APA/ADA 2004 consensus; APA 2024)
- Prolactin_monitoring_if_symptomatic_on_risperidone_paliperidone (APA 2024)

Monitoring

Regimen monitoring:
- PANSS or BPRS q 2 4 weeks acute phase (APA 2024)
- C-SSRS every visit (Palmer Arch Gen Psychiatry 2005; APA 2024)
- Weight BMI monthly x 3 then quarterly (APA/ADA 2004 consensus; APA 2024)
- Fasting glucose A1c at 3 months then annually (APA/ADA 2004; APA 2024)
- Fasting lipids at 3 months then annually (APA/ADA 2004; APA 2024)
- BP at each visit (APA/ADA 2004; APA 2024)
- Prolactin if symptomatic galactorrhoea amenorrhoea sexual dysfunction (APA 2024)
- EPS AIMS q 6 months (APA 2024)
- Clozapine ANC weekly x 6mo biweekly x 6mo then monthly (APA 2024; clozapine REMS)
- Clozapine trough level target 350 600 ng mL (APA 2024; PORT Buchanan Schizophr Bull 2010)
- ECG QTc if on ziprasidone or high dose antipsychotic (APA 2024; FDA)
- Continue antipsychotic >=1 2yr after first episode remission (APA 2024; PORT Buchanan Schizophr Bull 2010)

Setting (outpatient) monitoring:
- PANSS/BPRS at each visit during acute phase (q 2–4 weeks), then q 3 months in maintenance (APA 2024)
- C-SSRS at every visit (Palmer Arch Gen Psychiatry 2005; APA 2024)
- Weight/BMI monthly × 3 months then quarterly (APA/ADA 2004; APA 2024)
- Fasting glucose/A1c at 3 months then annually (APA/ADA 2004; APA 2024)
- Fasting lipids at 3 months then annually (APA/ADA 2004; APA 2024)
- BP at each visit (APA/ADA 2004; APA 2024)
- AIMS q 6 months (APA 2024)
- Clozapine ANC per REMS schedule if on clozapine (APA 2024)
- Prolactin if symptomatic (APA 2024)
- Functional outcomes q 3–6 months — employment, education, social (RAISE-ETP Kane AJP 2016)

Follow-up plan: 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)
- Close-out criterion: Maintenance plan in place with CSC team (APA 2024)

Monitoring phase: PANSS/BPRS q 2–4 weeks during acute phase (APA 2024); metabolic monitoring: weight/BMI monthly × 3 months then quarterly, glucose/A1c at 3 months then annually, lipids at 3 months then annually (APA/ADA 2004 consensus); prolactin if symptomatic; EPS/AIMS q 6 months; C-SSRS at every visit (Palmer Arch Gen Psychiatry 2005); response defined as ≥20% PANSS reduction by 2 weeks predicts outcome (Leucht Lancet 2013)

Disposition

Current setting: outpatient — Coordinated specialty care (CSC) — sustained antipsychotic optimisation, CBTp, family psychoeducation, supported employment/education, substance use treatment, relapse prevention (RAISE-ETP Kane AJP 2016; NAVIGATE Robinson NEJM 2015; APA 2024)

Disposition criteria:
- Continue CSC ≥2 years per RAISE-ETP (Kane AJP 2016) / NAVIGATE (Robinson NEJM 2015) model
- Step down to general outpatient psychiatry after sustained remission ≥2 years, stable functioning, medication adherence, family support (APA 2024)
- Refer to community mental health if CSC time-limited and ongoing support needed (APA 2024; NICE 2024)
- Refer to clozapine clinic if on clozapine for ongoing ANC monitoring and management (APA 2024)

Escalation triggers (move to higher acuity):
- Active SI with intent / plan / means → ED evaluation + possible inpatient admission (APA 2024; Palmer Arch Gen Psychiatry 2005)
- Relapse with acute psychosis + safety concern → ED or direct admit (APA 2024)
- NMS signs → ED immediately, discontinue antipsychotic (APA 2024)
- Clozapine ANC <1000/uL → hold clozapine, urgent haematology consult (APA 2024; clozapine REMS)
- Command hallucinations to harm self or others → urgent safety evaluation (APA 2024)
- Severe metabolic complications (new-onset diabetes, DKA) → medical evaluation (APA/ADA 2004; APA 2024)

Patient Action Plan

**First-episode psychosis action plan — early warning signs + relapse prevention (APA 2024; RAISE-ETP Kane AJP 2016)**
Personalised values: baseline_PANSS, current_antipsychotic_and_dose, identified_supports, crisis_line_numbers, CSC_team_contact, substance_use_triggers.

**Doing well — symptoms controlled, functioning improving, medication adherent (APA 2024; NAVIGATE Robinson NEJM 2015)** (green):
Triggers:
- 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)
Actions:
- 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)

**Caution — early warning signs of relapse, stress, or adherence lapse (APA 2024; NICE 2024)** (yellow):
Triggers:
- 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)
Actions:
- 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)
Contact provider when:
- 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)

**Medical alert — acute psychosis, command hallucinations, suicidality, catatonia, NMS signs (APA 2024)** (red):
Triggers:
- 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)
Actions:
- 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)
Contact provider when:
- Any red zone trigger — emergency department immediately (APA 2024)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] 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] Hyperthermia >38C, lead-pipe rigidity, altered consciousness, autonomic instability, CK elevation after antipsychotic exposure — Levenson criteria (APA 2024)

Citations

- 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 [PMID:26482160](https://pubmed.ncbi.nlm.nih.gov/26482160/)
- Cited evidence (PMID 26844794) [PMID:26844794](https://pubmed.ncbi.nlm.nih.gov/26844794/)
- Cited evidence (PMID 20513679) [PMID:20513679](https://pubmed.ncbi.nlm.nih.gov/20513679/)
- Cited evidence (PMID 23498057) [PMID:23498057](https://pubmed.ncbi.nlm.nih.gov/23498057/)
- Cited evidence (PMID 16172208) [PMID:16172208](https://pubmed.ncbi.nlm.nih.gov/16172208/)

Last reconciled with current guidelines: 2026-05-14.
References
  • 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 — PMID:26482160
  • Cited evidence (PMID 26844794) — PMID:26844794
  • Cited evidence (PMID 20513679) — PMID:20513679
  • Cited evidence (PMID 23498057) — PMID:23498057
  • Cited evidence (PMID 16172208) — PMID:16172208