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2. Node 1: Drugs Not Recommended at Node 1
David N. Osser, MD
Associate Professor of Psychiatry
Harvard Medical School
Brockton Division of the VA Boston Healthcare System
General Editor - Psychopharmacology Algorithm Project
Harvard South Shore Residency Training Program

3. Not recommended for first-onset patients
Clozapine
Olanzapine
Quetiapine

4. Active suicide thoughts and behavior
1st Trial
2nd Trial
Clozapine
Clozapine
Clozapine
Active suicide thoughts and behavior

5. Olanzapine Not recommended as first-line agent
Severe weight gain and metabolic effects
Even one dose:
Insulin resistance
Endocrine/ inflammatory dysfunction

6. Olanzapine Not recommended as first-line agent
Severe weight gain and metabolic effects
Even one dose:
Insulin resistance
Endocrine/ inflammatory dysfunction
Hahn, M. K., Wolever, T. M., Arenovich, T., Teo, C., Giacca, A., Powell, V., ... & Gomes, S. (2013). Acute effects of single-dose olanzapine on metabolic, endocrine, and inflammatory markers in healthy controls. Journal of clinical psychopharmacology, 33(6),

7. Quetiapine Higher weight gain and metabolic problems than: Risperidone
Ziprasidone
CAFÉ study
Weight gain: second to olanzapine
QTc prolongation warning
Time to rehospitalization
Poor maintenance effectiveness

8. Quetiapine Higher weight gain and metabolic problems than: Risperidone
Ziprasidone
CAFÉ study
Weight gain: second only to olanzapine
QTc prolongation warning
Time to rehospitalization
Poor maintenance effectiveness
Patel, J. K., Buckley, P. F., Woolson, S., Hamer, R. M., McEvoy, J. P., Perkins, D. O., ... & Cafe Investigators. (2009). Metabolic profiles of second-generation antipsychotics in early psychosis: findings from the CAFE study. Schizophrenia research, 111(1), 9-16.

9. Quetiapine Higher weight gain and metabolic problems than: Risperidone
Ziprasidone
CAFÉ study
Weight gain: second only to olanzapine
QTc prolongation warning
Time to rehospitalization
Poor maintenance effectiveness

10. Quetiapine Higher weight gain and metabolic problems than: Risperidone
Ziprasidone
CAFÉ study
Weight gain: second to olanzapine
QTc prolongation warning
Time to rehospitalization
Poor maintenance effectiveness
Kreyenbuhl, J., Slade, E. P., Medoff, D. R., Brown, C. H., Ehrenreich, B., Afful, J., & Dixon, L. B. (2011). Time to discontinuation of first-and second-generation antipsychotic medications in the treatment of schizophrenia. Schizophrenia research, 131(1),

11. Not a first-line agent Quetiapine
Higher weight gain and metabolic problems than:
Risperidone
Ziprasidone
CAFÉ study
Weight gain: second to olanzapine
QTc prolongation warning
Time to rehospitalization
Poor maintenance effectiveness
Not a first-line agent

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