Strategic and tactic use of antipsychotic medications in schizophrenia: a perspective on current prescription practice

Antipsychotic medications (APs) are pivotal in treating schizophrenia, alleviating symptoms like delusions, hallucinations, and disorganized behavior. APs can induce extrapyramidal symptoms and sedation, complicating chronic use but aiding in acute management. AP-induced metabolic syndrome, a primary factor in reduced life expectancy, is not a major concern during short-term treatment. Studies on APs efficacy yield mixed results, leading to trial-and-error prescribing practices. Meta-analyses indicate clozapine, amisulpride, olanzapine, and risperidone as effective in acute settings, with olanzapine and haloperidol beneficial for SZ-related agitation. Empirical observations suggest higher potency APs, like olanzapine and haloperidol, are more effective in acute psychosis, with zuclopenthixol also advantageous for its sedative properties. Cariprazine, lurasidone, low-dose amisulpride, brexpiprazole and aripiprazole showed a favorable side effects profile and a potential benefit on negative symptoms. My proposal in this perspective paper is to consider schizophrenia as a relapsing-remitting disorder, requiring a different pharmacological approach in the acute and maintenance phases. In the initial phase a high-dose, high-potency and fast-titrating AP should be used, for rapid symptoms' control (i.e. haloperidol, olanzapine, risperidone, high-dose amisulpride, zuchlopenthixol), defined as a tactic AP. Once the acute phase resolved, patients should be gradually switched towards a medication with fewer side effects (i.e. metabolic syndrome, extrapyramidal symptoms, hyperprolactinemia) and a potential efficacy on negative symptoms and personal functioning (i.e. cariprazine, low-dose amisulpride, lurasidone, aripiprazole, brexpiprazole), to be continued in the long term, defined as a strategic AP. This approach aligns with empirical observations and aims to refine schizophrenia care through phase-specific APs use, necessitating further studies to validate its efficacy.