Atypical antipsychotics for children and adolescents with schizophrenia-spectrum disorders

The choice of medication is up to the treating clinician. There are clear advantages to the atypical antipsychotics compared with placebo. The atypical antipsychotics are roughly equivalent in efficacy. However, adverse-effect profiles are markedly different. In the case vignette, for example, severe extrapyramidal symptoms were triggered by 30 mg of aripiprazole, which necessitated a switch to quetiapine. Adolescent patients with schizophrenia begin to show improvement by the second week of treatment that can be differentiated from improvement seen with placebo. Positive symptoms respond fairly quickly, but dramatic improvements may take a month or more. Improvements in the negative symptoms, cognitive function and anxiety, may take longer than 6 weeks. In the studies with quetiapine, aripiprazole, and risperidone, improvement was seen more quickly with higher doses than with lower doses in the first several weeks. However, by the end of the 6 weeks, responses to higher and lower doses were approximately equivalent. Using higher doses in an attempt to achieve more rapid results must be balanced against the increased risks of adverse effects. This was especially seen with the aripiprazole study: 10 mg may be the preferable target dose for adolescent patients. Weight gain and metabolic factors are yet another consideration. Especially for olanzapine and to some extent for risperidone and quetiapine, careful monitoring is needed to prevent weight gain from becoming a significant problem. Preliminary data suggest that metformin may be a safe and effective way of stopping weight gain, increasing insulin sensitivity, and thereby protecting patients, especially patients who are being treated with olanzapine.