Explaining a first-generation antipsychotic and EPS risks (CASC)

Station instructions (candidate)

You have 7 minutes. Explain why a first-generation antipsychotic is being considered after metabolic harm on olanzapine, what major trials say about effectiveness and quality of life versus “newer” drugs, what movement side effects to watch for (stiffness, restlessness, rare lock-jaw emergency), how low modern dosing and monitoring reduce risk, and that long-term abnormal movements are more common with older drugs but can occur with newer ones too. Offer choice, written information, and a clear safety net. Do not coerce depot. Do not guarantee zero side effects. Do not dismiss his fears.[1][2][3]

Marking domains

Empathy and agenda; accurate plain-language efficacy (CATIE/CUtLASS-informed); honest EPS/akathisia/TD counselling; modern low-dose and monitoring plan; emergency dystonia advice; collaborative choice including alternatives; when failure of two adequate trials would prompt clozapine discussion rather than endless switches.[1][2][3][4][5]

Model communication map

1. Open: thank him; acknowledge weight/diabetes fear and the “old drug” reputation; share goal of staying well with fewer metabolic harms.[1]
2. Why still used: large trials found some older medicines worked about as well as many newer ones for schizophrenia symptoms and life quality is not automatically better on newer drugs alone — choice is about side-effect fit, not marketing date.[1][2]
3. What we worry about: stiffness, tremor, restlessness (akathisia — can feel like you need to pace), and over years a risk of abnormal face/tongue movements; that risk is higher with older drugs but not zero with newer ones.[3][4]
4. How we reduce risk: start low, review early, treat lock-jaw/stiffness urgently with an antidote injection if needed, do not push the dose up if he feels restless — call us.[4]
5. Depot optional: only if tablets are hard to stick with after he has tried the oral version safely — not a punishment.[1]
6. If still unwell later: if two proper medicine trials fail, we talk about clozapine, not endless swaps.[5]
7. Close: questions, written info, next review date, crisis contacts, who to call for dystonia or severe restlessness.

Common fails

• Agreeing “old drugs never work” or “new drugs never cause TD.”[1][3]
• Ignoring metabolic reason for considering FGA.[1]
• Coercing depot without capacity/shared decision framing.
• No safety-net for dystonia or akathisia.[4]
• Promising zero movement side effects.[3]