Vital Harmony · clinical tools

Antipsychotic equivalence

Converted through olanzapine equivalents. Two published methods are shown because they disagree — sometimes substantially — and which one produced a number matters more than the number.

Method

Equivalent doses

Equivalence is a population average, not a switch instruction. The methods were derived from acute schizophrenia trials. They do not transfer cleanly to bipolar maintenance, augmentation in depression, or irritability indications, and they say nothing about how a particular patient will respond or tolerate.

Cross-titrate; do not substitute at the equivalent dose. Receptor profiles differ enough that an equivalent dose can still produce cholinergic or histaminergic rebound — coming off olanzapine or quetiapine onto an agent without those affinities is the common example.

Where the two methods diverge, treat that as information. Quetiapine is the clearest case: the two methods differ by more than 50%, which tells you the evidence itself is unsettled rather than that one figure is wrong.

Sources: Leucht S et al. Dose-response meta-analysis of antipsychotic drugs for acute schizophrenia. Am J Psychiatry 2020;177:342–353 · Leucht S et al. Dose equivalents for second-generation antipsychotics: the minimum effective dose method. Schizophr Bull 2014;40:314–326.

Benzodiazepine equivalence & taper

Diazepam-equivalent conversion, then a schedule rounded to strengths that can actually be dispensed.

Current regimen

Taper rate

Schedule

Benzodiazepine withdrawal can cause seizures and delirium. Unlike opioid withdrawal, it can be fatal. Abrupt discontinuation is never appropriate in a physically dependent patient, and the risk rises with dose, duration, and short half-life agents.

Consider converting to diazepam first. Its long half-life smooths the inter-dose troughs that make alprazolam tapers so difficult. The tradeoff is accumulation in the elderly and in hepatic impairment, where a shorter agent such as oxazepam or lorazepam may be safer.

The equivalences are contested. The Ashton ratios were derived for withdrawal management, not for acute substitution, and alprazolam and clonazepam potency estimates vary between sources. Convert conservatively and titrate to the patient rather than to the table.

Pauses are part of the plan. Holding a dose for several weeks when symptoms flare is a normal taper, not a failure. Slower is nearly always better tolerated, and the final third is the hardest part.

Equivalence: Ashton CH. Benzodiazepines: how they work and how to withdraw. Newcastle University, 2002 · Taper rates reflect current deprescribing guidance and vary widely by source.

Switching & titration

What goes wrong during a switch is predictable from the two agents' profiles. Protocols covers the three ladders where the schedule itself is the safety measure.

View

Cross-titration guidance is expert consensus, not trial evidence. Very few switches have been studied head to head. The hazards below are derived from receptor pharmacology and case experience — they tell you what to watch for, not what will happen.

The patient's history outranks the table. Someone who has previously destabilised on a fast switch, or who is acutely unwell, needs a slower cross-taper than any general rule produces.

Sources: FDA prescribing information for each agent · Maudsley Prescribing Guidelines principles for switching · MAOI intervals per product labeling.

Monitoring schedules

Enter a start date and get the dates the labs are due. Nothing is saved — this computes, it does not track.

These are schedules, not a record. The result of every lab belongs in the chart. This tool tells you when, never what happened.

Sources: FDA prescribing information for each agent · ADA/APA consensus on antipsychotic metabolic monitoring · FDA drug safety communication on clozapine REMS removal, effective 13 June 2025.

Esketamine session planner

Two views of the same session. Planning lays out the schedule; Administering shows what the person in the room needs.

View

The REMS record lives elsewhere. Enrollment, administration, and monitoring documentation belong in the chart and the REMS system. Nothing entered here is saved; close the tab and it is gone. Use this to plan and time the session, not to document it.

This session

Monitoring window

Before dosing

Before release

Build the schedule

Anchoring on the last completed session rather than session 1 means a missed week shifts everything after it, instead of the schedule arguing with reality.

Phase reference

PhaseFrequencySessions
Induction · weeks 1–4Twice weekly1–8
Maintenance · weeks 5–8Once weekly9–12
Maintenance · week 9 onwardEvery 1–2 weeks13+

Day 1 starts at 56 mg. Subsequent sessions are 56 or 84 mg by response and tolerability. Evidence of therapeutic benefit should be assessed at the end of induction to decide on continued treatment. Maintenance frequency is individualised — in the SUSTAIN trials patients moved between weekly and every-other-week repeatedly.

Two hours, every session, no exceptions. Monitoring runs at least 2 hours with pulse oximetry, followed by an assessment that the patient is clinically stable before leaving. Blood pressure before dosing and again at 40 minutes.

No driving until the next day after restful sleep. Confirm the ride home before dosing, not after.

Now approved as monotherapy for treatment-resistant depression as well as in conjunction with an oral antidepressant. The schedule is unchanged. REMS-certified setting, in-clinic administration.

Source: SPRAVATO (esketamine) prescribing information, FDA · SPRAVATO REMS.

Urgent reference

The things that go wrong quickly, and the intervals that prevent them.

Serotonin syndrome vs NMS

Serotonin syndromeNMS
OnsetHoursDays to weeks
NeuromuscularHyperreflexia, clonus — greatest in the legsLead-pipe rigidity, bradyreflexia
PupilsMydriasisNormal
Bowel soundsHyperactiveNormal or decreased
TriggerSerotonergic agent added or increasedDopamine antagonist, or dopamine agonist withdrawn
CourseResolves in 24 h with removalDays to weeks
Clonus is the discriminator. If it is present, serotonin syndrome is far more likely than NMS. Both present with fever, autonomic instability, and altered mentation — the neuromuscular exam is what separates them at the bedside.
Both are emergencies. Stop the offending agent, cool actively, and transfer. Hyperthermia above 41.1 °C requires sedation, paralysis, and intubation. Do not treat either with an antipsychotic.

MAOI washout

Fluoxetine is the trap. Its active metabolite norfluoxetine has a half-life measured in weeks, which is why the interval is five weeks rather than the two used for other SSRIs.

The washout runs in both directions. Two weeks after stopping an MAOI before starting a serotonergic agent, and the intervals above before starting an MAOI. Also applies to linezolid, methylene blue, meperidine, tramadol, dextromethorphan, and triptans.

Citalopram & escitalopram — QTc ceilings

Escitalopram carries no equivalent FDA dose restriction, though the maximum is 20 mg daily in patients over 60, with hepatic impairment, or on a CYP2C19 inhibitor.

Lithium levels

Toxicity is not a number alone. A patient can be toxic within the therapeutic range, particularly when chronic. Check the level, but treat the patient: tremor coarsening, ataxia, confusion, and vomiting matter more than the assay. Dehydration, NSAIDs, ACE inhibitors, thiazides, and acute illness are the usual precipitants.

Sources: FDA prescribing information and drug safety communications · Boyer & Shannon, N Engl J Med 2005;352:1112–20 (Hunter criteria).