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How do we select an antipsychotic for those with schizophrenia?

Schizophrenia is a severe progressive and debilitating condition, comprised of three primary symptom domains: positive, negative, and cognitive. Individuals with schizophrenia have a decreased life expectancy and suffer from a wide range of somatic conditions [1]. The etiology of schizophrenia is unclear, and there are likely many different pathophysiological pathways involving the interaction between dopamine and glutamate [2]. The mainstay of treatment for schizophrenia is antipsychotic medications, which function by antagonism or partial agonism at the dopamine D2 receptor. Second generation antipsychotics (SGAs) also function at other receptors, including antagonizing serotonin at the 5-HT2a receptor. Although these medications may lessen positive symptoms, negative and cognitive symptoms are less likely to improve. Antipsychotic medications can also precipitate movement disorders, such as extrapyramidal symptoms (EPS) and tardive dyskinesia (TD), metabolic syndrome, and other distressing side effects. Despite this, antipsychotic treatment adherence has been shown to prolong life [3]. Balancing the treatment of schizophrenia symptoms while concurrently managing antipsychotic induced side effects is a significant obstacle in treating schizophrenia. This paper will explore factors that go into selecting a medication for the treatment of schizophrenia, including antipsychotic efficacy and tolerability, and emphasize the critical importance of treatment adherence, especially during initial psychotic episodes.