When, if ever, do you consider prescribing clozapine after only one unsuccessful antipsychotic trial in schizophrenia?

I have read a recent JAMA Psychiatry paper concerning clozapine initiation after 1 antipsychotic trial, which was not successful (Li et al., PMID 41811299). I have not changed my practice, which is to require 2 such trials (which blood level confirmation to eliminate non-compliance) before prescribi...

This comes with experience. It depends on the level of psychosis as well as the dose of the current antipsychotic being prescribed.

For example, if a patient is on Risperdal 4 mg PO BID and it doesn’t touch the psychosis, then I’m thinking we need to try Zyprexa or Clozaril.

However, when you start ...

No, it is not my first choice after failure with one antipsychotic.

Check if the patient is compliant with med. Most of them are not! Find out use of recreational substances with antipsychotic, most commonly marijuana which is hallucinogenic.

I have never prescribed clozapine after a trial of just one antipsychotic.

I have seen horrible metabolic syndrome in my patients with clozapine.