Medication Options for Paranoid Schizophrenia

Paranoid schizophrenia (now classified as schizophrenia with prominent delusions/hallucinations) is treated primarily with antipsychotics. Treatment is individualized.

First-Line: Second-Generation (Atypical) Antipsychotics

• Risperidone, Olanzapine, Quetiapine, Aripiprazole, Paliperidone, Ziprasidone, Lurasidone, Cariprazine, Brexpiprazole
• Preferred: lower EPS risk, better negative/cognitive symptom profile.
• Clozapine: Gold standard for treatment-resistant (≥2 failed trials); requires ANC monitoring.

First-Generation (Typical) Antipsychotics

• Haloperidol, Fluphenazine, Perphenazine, Chlorpromazine.
• Higher EPS, tardive dyskinesia risk; used if atypicals fail or for cost.

Adjunctive Medications

• Antidepressants (SSRIs/SNRIs): Comorbid depression, negative symptoms.
• Mood stabilizers (Valproate, Lamotrigine, Lithium): Aggression, affective instability.
• Benzodiazepines: Short-term for agitation, anxiety, insomnia.
• Anticholinergics (Benztropine, Trihexyphenidyl): Prophylaxis/treatment of EPS.

Key Principles

• Start low, go slow; target therapeutic dose.
• Monitor: weight, metabolic panel, lipids, prolactin, EPS (AIMS), ANC (clozapine).
• LAI (long-acting injectable) formulations improve adherence.
• Psychosocial: CBT-p, family psychoeducation, supported employment, ACT teams.

Shared decision-making and regular review essential.