Professor Dan Siskind1
1Metro South Mental Health Service, Brisbane, Australia
Biography:
Dan Siskind trained in Australia and the US and has a long experience as a staff specialist at the Princess Alexandra Hospital, Brisbane. He is an adjunct professor of the Queensland Brain Institute, University of Queensland. His research interests include treatment refractory schizophrenia, clozapine and physical health co-morbidities. With over 300 publications, he is first author in The Lancet, BJPsych, Lancet Psychiatry, ANZJP and EPS and has published in the BMJ and World Psychiatry. He has over $60million in competitive research grants, with over $7 million as CIA. He was the SIRS 2026 Outstanding Clinical and Community Research Award recipient.
Abstract:
Schizophrenia carries a substantial and rising global disease burden, yet delays in optimal treatment remain common. The Bondi Junction Coronial Inquest (Recommendation 2) called for prompt amendment of the guidelines on the management of schizophrenia, noting both the ANZJP GRADE Guidelines being considered for RANZCP endorsement and the already endorsed INTEGRATE Guidelines. This presentation draws on both those resources to outline a contemporary, evidence-based approach across the illness course.
For first-line prescribing, given broadly comparable efficacy across antipsychotics (clozapine excepted), tolerability—particularly cardiometabolic side effects—should drive medication choice, favouring better-tolerated oral second-generation agents (aripiprazole, brexpiprazole, cariprazine, lurasidone) from illness onset, with metabolic monitoring from initiation.
For first-episode psychosis responsive to treatment, maintenance therapy reduces relapse and hospitalisation with high-certainty evidence. Complete discontinuation may be considered only after sustained full remission—typically beyond two years—without prior relapse on withdrawal, weighing relapse risk against the harms of continued treatment.
When deprescribing is clinically appropriate, the lowest effective dose should always be used, and discontinuation should proceed as a gradual taper over at least six months, supported by psychoeducation on relapse risk factors and early warning signs.
For treatment-resistant schizophrenia—inadequate response to two adequately dosed antipsychotics with confirmed adherence—clozapine should be offered promptly, guided by plasma-level monitoring, with augmentation, electroconvulsive therapy, or selected antidepressants where response remains incomplete. If effective, clozapine treatment should be indefinite.
Aligning these recommendations offers clinicians a coherent, algorithmic framework spanning initiation, maintenance, deprescribing and treatment resistance, and responds directly to the recommendation of the Coroner for timely, evidence-based guidance.