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Psychosis — Recognition & Treatment

First-episode psychosis needs same-day referral to EPPIC

Field: Mental HealthCode: MH-04AUpdated: June 2026Reference: RANZCP/ANZJP GRADE 2026
All first-episode psychosis needs same-day referral to an early psychosis service (e.g. EPPIC). First-line antipsychotic choice now favours aripiprazole, brexpiprazole, cariprazine or lurasidone for their cardiometabolic profile; clozapine after 2 failed trials.

Recognising acute psychosis

  • Positive symptoms: hallucinations (auditory more than visual), delusions, thought disorder, bizarre behaviour.
  • Negative symptoms: flat affect, social withdrawal, amotivation, poverty of speech.
  • Cognitive symptoms: disorganisation, poor concentration, impaired memory, reduced executive function.
  • Prodrome: subtle social withdrawal, declining function, sleep change — over weeks to months.
  • Red flags: self-neglect, command hallucinations, paranoid delusions about specific people, catatonia.

First-line antipsychotics

Selected for cardiometabolic profile, per the RANZCP/ANZJP 2026 GRADE guideline.

1
Aripiprazole: D2 partial agonist — lowest weight gain among the options, PBS-funded; watch for akathisia and insomnia.
2
Brexpiprazole: D2 partial agonist — newer, generally well tolerated; watch for akathisia and (lesser) weight gain.
3
Cariprazine: D2/D3 partial agonist — relatively favoured for negative symptoms; watch for akathisia and extrapyramidal symptoms.
4
Lurasidone: D2 antagonist — low weight gain, but must be taken with food (around 350 calories) for adequate absorption; watch for akathisia.
Other options. Risperidone — older first-line option, available as a long-acting injectable; watch for hyperprolactinaemia and extrapyramidal symptoms. Olanzapine — often highly effective, but carries higher metabolic risk; consider co-commencing metformin; watch for weight gain, dyslipidaemia and type 2 diabetes. Quetiapine — sedating, sometimes used off-label for sleep or anxiety; watch for sedation, metabolic effects and postural hypotension.

Safety

  • All antipsychotics carry cardiometabolic risk — check baseline weight, BP, glucose and lipids before starting, whichever agent is chosen.
  • Olanzapine and clozapine carry the highest metabolic risk — consider co-commencing metformin from the outset.
  • Lurasidone needs food (around 350 calories) for adequate absorption — counsel patients explicitly, or efficacy may be reduced.

Red flags / refer

  • First-episode psychosis, any presentation → refer to an early psychosis service (e.g. EPPIC) the same day.
  • Self-harm risk, harm to others, or command hallucinations → same-day Crisis Assessment and Treatment Team (CATT) or ED.
  • No response after 2 adequate antipsychotic trials → clozapine work-up via psychiatry.

MH-04A v1.0 · Reviewed Jun 2026 · Review Jun 2027

For health-professional use. Framework: RANZCP/ANZJP GRADE Schizophrenia Guideline (Suetani et al, 2026). Companion sheet: MH-04B Antipsychotics — Monitoring & Side Effects.