If you are in an emergency, in crisis or need someone to talk to, there is help.

View Crisis Resouces
Skip to content
  • Contact Us
  • No One Left Behind
  • Join our team
  • Referral Form
  • Virtual Urgent Care
  • Accessibility
CAMH logo
  • Patients and Families
    • Main Page
    • Access CAMH & Referral Form
      • Access CAMH

        Centralized information, intake and scheduling. Access CAMH makes it easy to find support – simply call 416-535-8501, option 2.

      • Referral Form

        For mental health services, a referral form needs to be completed by a healthcare provider. For addictions services, patient can self-refer.

    • Programs & Services
      • Addictions/Substance Use
      • Alzheimer’s & Dementia
      • Anxiety & Depression
      • Concurrent Disorders
      • Developmental Disabilities
      • Mood & Personality Disorders
      • Problem Gambling
      • Schizophrenia & Psychosis
      • Trauma & Stress Disorders
      • Virtual Mental Health and Outreach
      • Other
    • Information for Patients
      • Patient Wellness and Patient Engagement at CAMH
      • What to expect
      • Your Rights
      • Patient and Family Feedback
      • Visiting CAMH

        Planning on visiting CAMH? Find contact information, directions and accessibility for each of our three main sites.

    • Information for Families
      • Family Resource Centre
      • Patient and Family Feedback
      • Visiting CAMH

        Planning on visiting CAMH? Find contact information, directions and accessibility for each of our three main sites.

    • Patient and Family Engagement
      • Patient and Family Partners Program
      • Information and resources
      • Get Involved in Research
      • Volunteer at CAMH
    • Visiting CAMH
      • Visiting CAMH

        Planning on visiting CAMH? Find contact information, directions and accessibility for each of our three main sites.

        Read More
    • MyCAMH
  • Health Info
    • Main Page
    • Mental Illness & Addiction Index
      • Conditions & Disorders
      • Medication Therapies
      • Substance Use
      • Types of Treatment
      • Information in Other Languages
    • Mental Health 101
      • Mental Health 101

        Use this series of free online tutorials as the starting point to learn about and understand a wide range of mental health topics.

        Read More
    • Guides & Publications
      • Guides & Publications

        Accessible, reliable, professionally produced resources on an array of mental health topics for patients, families, students and professionals.

        Read More
    • Crisis Resources
      • Crisis Resources

        If you are in an emergency, in crisis or need someone to talk to, there is a list of resources available for areas in and around Toronto.

        Read More
    • CAMH Store
      • CAMH Store

        The CAMH Store offers a wide array of mental illness and addiction resources for patients, families, students and professionals. Search or browse our catalogue of brochures and booklets, textbooks, manuals and assessment tools.

        Read More
    • CAMH Library
      • CAMH Library

        Open to professionals and the general public, our comprehensive resources and services support and enhance CAMH's research and clinical programs, and they facilitate learning, dynamic knowledge exchange and health promotion initiatives.

        Read More
    • Workplace Mental Health Playbook
    • Mental Health and the COVID-19 Pandemic
      • Coping with stress & anxiety
      • Quarantine & isolation
      • Stigma and prejudice
      • Loss, grief and healing
      • Resources for Health Care Workers
  • Research
    • Main Page
    • Research Areas at CAMH
      • Brain Science

        CAMH is revolutionizing our understanding of the brain and the causes, biomarkers and treatments of mental illness.

      • Personalized Care

        By understanding diverse groups, we prevent, diagnose and care for each one with greater precision and personalization.

      • Prevention and Policy

        Using evidence, we drive system and social change to optimize care and reduce the burden of mental illness, including addictions, across populations.

    • The Discovery Fund
      • The Discovery Fund

        Fuelling the next generation of groundbreaking research and innovation dedicated to finding the causes of and cures for mental illness.

        Read More
    • Institutes & Centres
      • Azrieli Adult Neurodevelopmental Centre
      • Azrieli Centre for Neuro-Radiochemistry
      • Brain Health Imaging Centre
      • Campbell Family Mental Health Research Institute
      • Centre for Youth Bipolar Disorder
      • Cundill Centre for Child and Youth Depression
      • Institute for Mental Health Policy Research
      • Krembil Centre for Neuroinformatics
      • Slaight Family Centre for Youth in Transition
      • Tanenbaum Centre for Pharmacogenetics
      • Temerty Centre for Therapeutic Brain Intervention
      • The Margaret and Wallace McCain Centre for Child Youth & Family Mental Health
    • Clinical Divisions
      • Addictions Division
      • Adult Neurodevelopmental and Geriatric Psychiatry Division
      • Child and Youth Psychiatry Division
      • Forensic Psychiatry Division
      • General and Health Systems Psychiatry Division
      • Psychology Division
      • Schizophrenia Division
    • Research Discoveries
      • Research Discoveries

        At the leading edge of breakthrough mental health and addiction research for over 50 years.

      • BrainBuzz Newsletter

        The latest news, groundbreaking discoveries and special features about CAMH research, studies, and the people behind the work.

      • Research Strategic Plan

        Learn what drives our research agenda and priorities in the CAMH Research Plan for 2018-2023

    • Research Connect
      • Research Connect FAQs
      • Research Ethics
    • Koerner Centre for Research Training
      • Koerner Centre for Research Training

        Each year CAMH provides opportunities to the next generation of scientists: today’s undergraduate students, graduate students and postdoctoral researchers. Train in a unique learning environment and help contribute to the breakthrough mental health research and treatments of tomorrow

        Read More
    • Science & Research Staff Directory
      • Our Scientific Staff
      • Research Chairs at CAMH
    • Industry Partnerships & Technology Transfer Office (IPTTO)
  • Education
    • Main Page
    • Continuing Education Programs and Courses
      • Find the Course That's Right for You

        Browse our entire selection of certificate programs, webinars and workshops.

      • Workplace Education and Consulting Services

        View our full list of workplace mental health workshops and consulting services

    • Collaborative Learning College
    • Simulation Centre
    • TIDES
    • Student Centre
    • Clinical & Research Opportunities for Professionals in Training
      • Clinical Psychology Training Programs
      • Community-Based Research Fellowship
      • Graduate & Post-Doctoral Fellowships in Public Health Policy
      • Clinical & Research Opportunities for Professionals in Training

        Study in a world-class setting to become a leader in the field of mental health.

    • Research in Education
      • Academic & Education Research Excellence
      • Health Equity and Inclusion Framework for Education and Training
    • Evaluation
    • Workplace Mental Health Workshops and Consulting
    • CAMH Education Contacts
  • Professionals
    • Main Page
    • Treating Conditions & Disorders
      • NAVIGATE - Treating Psychosis in Youth
      • CARIBOU - Treating depression in youth
      • Virtual Mental Health
      • Alcohol Use
      • Anxiety Disorders
      • Dementia
      • Depression
      • Suicide Risk
      • Fundamentals of Addiction
      • Intellectual & Developmental Disabilities
      • Mania
      • OCD
      • Opioid use and opioid use disorder
      • Perinatal Mood & Anxiety Disorders
      • Personality Disorders
      • Psychosis
      • Posttraumatic Stress Disorder
      • Smoking Cessation
    • Professionals Projects
      • Climate Change and Mental Health
      • Health Care Access Research and Developmental Disabilities
      • Immigrant and Refugee Mental Health Project
      • Opioid Use in Primary Care Conference 2024
    • Networks
      • Psychiatry Partnerships with Northern Communities
    • Videos
    • Podcasts
  • Get Involved
    • Main Page
    • Ways to Donate
      • Give Monthly
      • Give In Memory or In Honour
      • Start a Fundraiser
      • Gifts of Celebration
      • Leave a Gift in Your Will
      • Employee Giving
      • Donate Goods & Services
      • Gifts of Securities
      • Canvassers & Callers
      • Make a one-time donation

        With your support, CAMH researchers are revolutionizing the ways we diagnose, treat, and prevent mental illness. Donate today.

    • Join the Cause
      • Corporate Partnerships
      • Business Leaders for Mental Health
      • CAMH Engage
      • womenmind
      • Visionary Society
      • Michael Wilson Society
      • Volunteer at CAMH
    • Making a Real Impact
      • Making a Real Impact

        Real stories of courage, hope and discovery. Made possible through your continued support of CAMH.

        Read More
  • Driving Change
    • Main Page
    • About CAMH
      • Leadership Team Directory
      • Performance & Accountability
      • The Role of CAMH Foundation
      • For Reporters
      • Events Calendar
      • For Our Neighbours
      • Contact CAMH
      • Careers at CAMH

        By working at CAMH, you can help people affected by mental illness and support their recovery. Join the team. Everyone who works at CAMH becomes an advocate for mental health.

    • The Crisis is Real
      • The Crisis is Real

        We are in the grips of a crisis that ruins health, threatens lives and hurts economies. Knowing the facts is the first step in creating hope.

      • Mental Health Statistics

        The latest facts and statistics on mental illness and addiction, who's affected and their impact on Canadians.

    • Addressing Stigma
      • Addressing Stigma

        Challenging the stigma associated with mental illness takes understanding, education and a closer look at our own attitudes toward health.

        Read More
    • The Mental Health Facility of the Future
      • The Mental Health Facility of the Future

        Turning what was once a walled institution into a symbol of hope for the future of mental health care.

      • Vision & Guiding Principles

        How do you replace an institution with an urban village? Lots of planning, imagination and a long-term commitment to serving patients, staff and the community.

      • History of Queen Street Site

        Our history—evolving from an asylum into a modern health facility with patients at the centre of care—is the history of mental health care in Canada.

    • Influencing Public Policy
      • Influencing Public Policy

        CAMH advocates for policies that are responsive to the needs of people with mental illness and addictions.

        Read More
    • Health Equity
      • Health Equity

        CAMH believes in the principle of equity. We respect the diversity of the individuals and communities we serve.

        Read More
    • Shkaabe Makwa
    • CAMH News & Stories
    • Strategic Plan
    • Contact Us
    • No One Left Behind
    • Join our team
    • Referral Form
    • Virtual Urgent Care
    • Accessibility

Psychosis: Treatment

CAMH Logo
  • Psychosis: Treatment
Back to top
  • Home
  • Professionals
  • Treating Conditions & Disorders
  • Psychosis
  • Treatment
CAMH logo
  • Psychosis
  • Screening & Assessment
  • Diagnosis
  • Treatment
  • Clinical Tools
Back to top

Text adapted from "The patient with Psychosis" in Psychiatry in primary care by George Foussias and Z. Jeff Daskalakis  (CAMH, 2019). 

The following section focuses on treating psychotic symptoms in the context of schizophrenia or schizoaffective disorder. The same general principles apply for treating psychosis in the context of other illnesses; however, the underlying illness must be addressed (e.g., psychosis in the context of delirium, major depressive episode with psychotic features).

Other treatments

Electroconvulsive Therapy (ECT) in combination with antipsychotic medication may offer some benefit for treatment-resistant psychotic symptoms. 

Psychopharmacology

Acute Treatment

The goal of acute treatment for a patient with psychosis is full remission of symptoms and return to baseline function. Acute treatment involves the following components:

  • diagnostic assessment
  • assessment of the potential for danger to self or others
  • engagement of the patient and caregivers in the treatment process, which includes discussing risks and benefits of treatment
  • initiation of pharmacological treatment as soon as possible.

Second-generation antipsychotic medications (SGAs) are the first-choice treatments, particularly for previously unmedicated patients who are particularly sensitive to acute extrapyramidal and sedative side-effects caused by antipsychotics.

The SGAs, including olanzapine, risperidone, paliperidone, quetiapine, ziprasidone, aripiprazole, asenapine and lurasidone, offer improved tolerability, particularly with regard to extrapyramidal symptoms, compared with first-generation antipsychotics (FGAs) (see Table 1).

Usually there is not one definite choice of medication for any given patient because there is much individual variability in efficacy and side-effects. The choice of antipsychotic is based primarily on individual profiles of efficacy and tolerability:

  • All SGAs, except clozapine, appear to be equally effective in treating psychosis in schizophrenia, with some recent evidence suggesting a slight advantage for olanzapine.
  • SGAs, except clozapine, and FGAs appear to be equally effective in treating schizophrenia and schizoaffective disorder.
  • Clozapine has unique efficacy in treatment-resistant schizophrenia and schizoaffective disorder (patients who have not benefited from previous trials of two antipsychotics).
  • All antipsychotics carry a risk of extrapyramidal symptoms and tardive dyskinesia, although the risk appears to be higher with FGAs than SGAs. Of the SGAs, the risk of extrapyramidal symptoms appears to be highest with risperidone and paliperidone.
  • All antipsychotics carry a risk of weight gain and metabolic abnormalities, although the risk appears to be higher with SGAs, particularly olanzapine, quetiapine and clozapine.
  • Risperidone and paliperidone are the SGAs most commonly associated with elevated prolactin levels and subsequent amenorrhea and sexual dysfunction.
  • Ziprasidone carries a potential risk of QTc prolongation and, as such, is contraindicated in patients with a prolonged QTc interval.
  • Clozapine carries a risk of agranulocytosis, which requires regularly monitoring white blood cell and neutrophil counts (weekly for the first six months, every two weeks for the next six months, monthly thereafter). The risk is approximately one percent, and appears to be greatest in the early stages of treatment. Clozapine commonly causes constipation (in about 14 percent of patients), and appropriate monitoring and intervention is recommended.
  • Treatment of schizoaffective disorder typically involves a combination of an antipsychotic and a medication that targets the mood disturbance.

See Table 2 for recommended medication monitoring guidelines.

Other treatments

ECT in combination with antipsychotic medication may offer some benefit for treatment-resistant psychotic symptoms.

Related

  • Psychiatry in Primary Care: A Concise Canadian Pocket Guide 2019

    Read More

  • Psychosis: Health Information for your Patient

    Read More

  • Schizophrenia: Health Information for Your Patient

    Read More

  • Schizophrenia: An Information Guide

    Read More

Table 1 First- and second-generation antipsychotic medications

Second generation - oral: generic name (brand name)

Medication Starting Dose (mg/day) Usual Target Dose (mg/day) Maximum Dosea Frequency
Risperidone (Risperdal) 0.5 - 2 2 - 6 8 od or bid
Paliperidone (Invega) 3 - 6 3 - 12 12 od
Olanzapine (Zyprexa) 5 - 10 10 - 20 20 od
Quetiapine (Seroquel) 50 - 100 300 - 800 800 od or bid
Quetiapine XR (Seroquel XR) 300 400 - 800 800 od
Ziprasidone (Zeldox)b 80 120 - 160 200 bid with meals
Aripiprazole (Abilify) 10 - 15 10 - 30 30 od
Brexpiprazole (Rexulti) 1 2 - 4 4 od
Asenapine (Saphris) 10 10 20 bid
Lurasidone (Latuda)b 40 40 - 80 160 od with food
Clozapine (Clozaril) 12.5 - 25 300 - 600 900 od to tid

 

Second generation - depot: generic name (brand name)

Medication Starting Dose (mg/day) Usual Target Dose (mg/day) Maximum Dosea Frequency
Risperidone long-acting injectable (Risperdal Consta) 12.5–25 (oral supplementation required first 3 weeks) 25 - 37.5 50 q2 weeks
Paliperidone palmitate (Invega Sustenna) 150 (day 1)

100 (day 8)
75 - 150 150 q4 week
Aripiprazole (Abilify Maintena) 400 300 - 400 400 q4 weeks

 

First generation - oral: generic name (brand name)

Medication Starting Dose (mg/day) Usual Target Dose (mg/day) Maximum Dosea Frequency
Haloperidol (Haldol) 1 - 3 4 - 12 20 bid or tid
Fluphenazine (Moditen) 2.5 - 10 1 - 5 20 od to tid
Flupenthixol (Fluanxol) 1 - 3 3 - 6 12 tid
Perphenazine (Trilafon) 8 - 16 16 - 64 64 bid to qid
Loxapine (Loxapac) 10 - 50 60 - 100 250 bid to qid
Zuclopenthixol (Clopixol) 10 - 50 20 - 60 100 bid or tid

 

First generation - depot: generic name (brand name) 



Medication Starting dose (mg/ day) Usual target dose (mg/day) Maximum dose (mg/day)a Frequency
Haloperidol decanoate (Haldol LA) 25 50 - 200 300 q4 weeks
Fluphenazine decanoate (Modecate) 2.5 - 12.5 12.5 - 50 100 q2 - 4 weeks
Flupenthixol decanoate (Fluanxol Depot) 5 - 20 20 - 80 80 q2 - 3 weeks
Zuclopenthixol acetate (Clopixol Acuphase) 25 - 50 50 - 150 400

(cumulative dose)
q2 - 3 days
Zuclopenthixol decanoate (Clopixol Depot) 100 - 200 150 - 300 400

q2 weeks
q2 - 4 weeks


Note: This is not an exhaustive list of all available FGA or FGA-depot antipsychotics. Dosages are for adult patients. In older adults, dosage adjustments may be necessary.

a Based on Compendium of Pharmaceuticals and Specialties values (Canadian Pharmacists Association, 2019) or, when not available, Clinical Handbook of Psychotropic Drugs, 22nd ed. (Procyshyn et al., 2017).
b Must be taken with food to ensure adequate medication absorption.

Table 2 Recommended Medication Monitoring Guidelines
Clinical and Laboratory Monitoring Monitoring Frequency
Acute phase Stable Phase
Individual and family history of illness Baseline Yearly
Smoking history Baseline and at 3 months Yearly
Body mass index, weight, waist circumference Baseline and at 1 and 3 months Yearly
Blood pressure Baseline, as indicated clinically, and at 3 months Yearly
HbA1C / fasting blood sugar Baseline and at 3 months Yearly, or more frequently if symptomatic or gaining weight
Random lipids / fasting lipids Baseline and at 3 months Yearly
Prolactin As indicated clinically As indicated clinically
Extrapyramidal symptoms (Parkinsonism, dystonia, dyskinesia, akathasia) Baseline and at 1 and 3 months Yearly
ECG As indicated clinically based on medical and family history, and before staring antipsychotics with Qtc effects.  As indicated clinically. 

Source: Pringsheim et al. (2017).

In Psychosis: 

  • The Role of the Primary Practitioner
  • Screening & Assessment
  • Diagnosis
  • Treatment
    • Pharmacotherapy
    • Psychotherapy
  • Resources 
  • References

Diagnosis
Pharmacology

Follow us
  • Patient and Family Care
  • Health Info
  • Science and Research
  • Education
  • Professionals
  • Get Involved
  • Driving Change
  • About CAMH
  • Job Openings
  • Purchase Publications
  • Referral Form
  • For Reporters
  • Donor Services
  • Events

CAMH Switchboard

From the GTA: 416 535-8501


Toll-free: 1 800 463-2338

To Access CAMH Clinical Services

416 535-8501, press 2

We have multiple locations. Find directions.

Map of CAMH's Queen Street Site
  • Staff Tools

Copyright 2025 CAMH

  • Terms of Use
  • Accessibility
  • Site Map

Keep in touch with CAMH

Keep your finger on our pulse – latest CAMH news, discoveries and ways to get involved delivered to your inbox.

Please select a newsletter

Please complete the following:

    Required Fields

    Please select a newsletter option

    Please input a first name

    Please input a last name

    Please input an email address

    By clicking Sign Up below, I consent to receive electronic communications (as selected above) from CAMH and CAMH Foundation. To unsubscribe at any time click the link in our mailing or email: unsubscribe@camh.ca

    Please agree to the Terms of Use

     

    Thanks for Subscribing.

    We look forward to keeping you informed, inspired and involved in all things CAMH.

    Double your impact this Mental Health Week

    Your gift to CAMH will now go twice as far to help change mental health care forever.

    $
    Other Ways to Give