From the Guidelines
The workup for acute psychosis should begin with a thorough history and physical examination to distinguish between primary psychiatric disorders and secondary causes, as recommended by the American Psychiatric Association 1. The initial assessment should include a review of psychiatric symptoms and trauma history, an assessment of tobacco use and other substance use, a psychiatric treatment history, an assessment of physical health, and an assessment of psychosocial and cultural factors, as outlined in the APA’s Practice Guidelines for the Psychiatric Evaluation of Adults 1. Initial laboratory tests should include complete blood count, comprehensive metabolic panel, thyroid function tests, urinalysis, urine drug screen, and blood alcohol level, as well as additional tests such as B12, folate, RPR/VDRL for syphilis, HIV testing, and ammonia levels, as suggested by the acr appropriateness criteria® altered mental status, coma, delirium, and psychosis: 2024 update 1. Some key points to consider in the workup include:
- Brain imaging with CT or MRI is indicated, especially with new-onset psychosis, neurological findings, or atypical presentation 1.
- An EEG may be necessary if seizure disorder is suspected.
- Lumbar puncture should be performed if CNS infection is a concern. For initial management, antipsychotic medications like risperidone (0.5-2mg twice daily), olanzapine (5-10mg daily), or haloperidol (2-5mg every 4-6 hours) can be used, with lower doses for elderly patients, as recommended by the APA 1. Benzodiazepines such as lorazepam (1-2mg every 4-6 hours) may help with agitation, and the patient should be placed in a safe environment with minimal stimulation. This comprehensive approach is essential because psychosis can result from various conditions including psychiatric disorders, substance use, metabolic disturbances, neurological conditions, or medications, and proper identification of the underlying cause directs appropriate treatment 1.
From the Research
Acute Psychosis Workup
- The primary goal in the workup of acute psychosis is to rapidly stabilize intense positive symptoms, hostility, and agitation 2.
- Selection of antipsychotic treatment should consider efficacy against positive symptoms and hostility, as well as speed of therapeutic onset 2.
- A study comparing oral treatment with risperidone and lorazepam versus intramuscular treatment with haloperidol and lorazepam found that both treatments were effective in controlling agitation and psychosis, with similar improvements in symptoms at 30,60, and 120 minutes after dosing 3.
- The initial management of acute psychosis involves establishing a therapeutic alliance, assessing the patient's risk, and deciding whether they can be managed in the community or require inpatient care 4.
- Comparisons of oral risperidone, olanzapine, and quetiapine with haloperidol have shown that these second-generation antipsychotics are as effective as haloperidol in treating psychotic agitation, with fewer extrapyramidal symptoms 5.
- A study on the onset of action of atypical and typical antipsychotics found that risperidone had a shorter onset of action compared to olanzapine, haloperidol, and thiothixene, with a mean time to first response of 6.15 ± 2.9 days 6.
Treatment Options
- Risperidone, olanzapine, and quetiapine are effective alternatives to haloperidol for the treatment of acute psychotic agitation 3, 5.
- These second-generation antipsychotics have a more favorable side-effect profile compared to typical antipsychotics like haloperidol 5.
- The choice of antipsychotic medication should be based on the individual patient's needs and medical history 2.
Assessment and Management
- Urgent assessment and management are essential in cases of acute psychosis, as there may be a danger to the patient and others 4.
- General practitioners may need to initiate initial treatment, especially in remote areas where specialist services may not be readily available 4.
- Establishing a therapeutic alliance and assessing the patient's risk are crucial steps in the initial management of acute psychosis 4.