A 29-year-old man with a first episode of schizophrenia is highly concerned about weight gain and sexual dysfunction, having read about these effects before starting treatment. He has no cardiac risk factors. Which antipsychotic is the most appropriate choice?

• A Olanzapine
• B Clozapine
• C Quetiapine
• D Aripiprazole ✓

Explanation

Aripiprazole is a dopamine D2 partial agonist and also a partial agonist at 5-HT1A receptors. Its intrinsic activity is low enough that it causes minimal weight gain, minimal prolactin elevation, and a favourable metabolic profile, making it the standard choice when these concerns dominate. Olanzapine and clozapine carry the highest weight gain and diabetes risk of all antipsychotics, and quetiapine is intermediate for metabolic effects. Partial agonism stabilizes dopamine signalling without producing the sustained blockade that drives hyperprolactinemia.

Reference: Katzung's Basic and Clinical Pharmacology, 16th ed.

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