Switching Antipsychotic Therapy: What to Expect and Clinical Strategies for Improving Therapeutic Outcomes

When a patient taking an antipsychotic is not experiencing symptomatic remission, or is experiencingadverse effects (AEs) that are intolerable or damaging to his or her physical health, a change inmedication may be the best path to a good outcome. However, many clinicians are reluctant to switchmedications in all but the clearest cases of failure. This reluctance is intensified by the occurrence ofAEs caused by transitioning patients too rapidly between agents with different receptor-binding profiles.Emergent antipsychotic-switching syndromes include the “withdrawal triad,” comprised of cholinergicrebound, supersensitivity psychosis, and emergent withdrawal dyskinesias (and other motorsyndromes). More recently, another element has been observed consistent with an activation syndrome.This activation syndrome may occur as a consequence of switching from highly sedativeagents or as a consequence of initial prodopaminergic drive. All of these effects can be minimized bycareful planning of gradual switch procedures and judicious use of adjunctive medications.