From the Editor

High-dose antipsychotics: A matter of opinion

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Like you, I always worry about being sued for malpractice. I comfort myself by knowing that not every psychiatrist—or even the majority—has to agree with the way I practice. To meet the “standard of care” and fulfill my duty to patients, my practice just needs to be endorsed by a respectable minority of practitioners.

Two articles in this issue illustrate the legitimate diversity of opinion within psychiatry. Drs. Joseph Pierre, Donna Wirshing, and William Wirshing at UCLA provide an excellent review on higher-than-recommended antipsychotic dosages for patients with treatment-refractory schizophrenia. They conclude that:

  • there is very little evidence that high dosages are more effective than usual dosages
  • patients who do not respond to usual dosages should be switched to clozapine before high-dose therapy is tried.

We invited Sheldon Preskorn, MD—a Current Psychiatry associate editor—to review the article. Based on his research in clinical psychopharmacology, he wrote a commentary to explain the variables that determine patient response to drug therapy. He suggests that:

  • some patients may need higher antipsychotic dosages, which might be tried before switching medications
  • plasma levels should be considered before changing treatments.

We’ll let you decide which approach or synthesis of approaches works for you. Whichever you choose will be supported by at least a respectable minority of practitioners.

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