How to manage an acute psychotic episode?

From the Guidelines

Managing an acute psychotic episode requires prompt intervention with both pharmacological and non-pharmacological approaches, with the most recent evidence from 2024 suggesting that treatment should be based on the underlying cause, control of symptoms with nonpharmacological approaches, medication when deemed appropriate, and effective aftercare planning 1.

Key Considerations

• Ensure safety by creating a calm environment, removing potential dangers, and having adequate staff present.
• For medication, antipsychotics are the mainstay of treatment, with atypical antipsychotics like risperidone, olanzapine, or haloperidol being preferred options.
• For agitated patients, intramuscular options include haloperidol, olanzapine, or ziprasidone, with benzodiazepines like lorazepam added for severe agitation if necessary.
• Monitor vital signs and watch for extrapyramidal side effects.
• Use verbal de-escalation techniques before medications when possible.
• Identify and address triggers like substance use or medication non-adherence.

Medication Options

• Risperidone (2-4mg) orally for cooperative patients.
• Haloperidol (2-5mg) orally for cooperative patients.
• Olanzapine (5-10mg) orally for cooperative patients.
• Intramuscular options: haloperidol 5mg, olanzapine 10mg, or ziprasidone 10-20mg for agitated patients.
• Benzodiazepines like lorazepam (1-2mg) for severe agitation.

Important Considerations

• Early intervention improves outcomes and reduces the risk of harm to the patient and others.
• Antipsychotics work by blocking dopamine receptors, particularly D2 receptors, which helps reduce hallucinations, delusions, and disorganized thinking.
• The economic impact of delirium and psychosis in the United States is profound, with total costs estimated at $38 to $152 billion each year 1.
• Treatment of primary causes of psychosis involves pharmacologic management with antipsychotic medications, psychological therapy, and psychosocial interventions 1.

From the FDA Drug Label

In a placebo-controlled trial in agitated inpatients meeting DSM-IV criteria for schizophrenia (n=270), 4 fixed intramuscular olanzapine for injection doses of 2.5 mg, 5 mg, 7. 5 mg and 10 mg were evaluated. All doses were statistically superior to placebo on the PANSS Excited Component at 2 hours post-injection. In a second placebo-controlled trial in agitated inpatients meeting DSM-IV criteria for schizophrenia (n=311), 1 fixed intramuscular olanzapine for injection dose of 10 mg was evaluated. Olanzapine for injection was statistically superior to placebo on the PANSS Excited Component at 2 hours post-injection. In a placebo-controlled trial in agitated inpatients meeting DSM-IV criteria for bipolar I disorder (and currently displaying an acute manic or mixed episode with or without psychotic features) (n=201), 1 fixed intramuscular olanzapine for injection dose of 10 mg was evaluated Olanzapine for injection was statistically superior to placebo on the PANSS Excited Component at 2 hours post-injection.

To manage an acute psychotic episode, intramuscular olanzapine can be used. The recommended dose is 2.5 mg, 5 mg, 7.5 mg, or 10 mg, with all doses being statistically superior to placebo on the PANSS Excited Component at 2 hours post-injection 2.

• Key considerations:
  • Patients should be judged by clinical investigators as clinically agitated and clinically appropriate candidates for treatment with intramuscular medication.
  • Patients should be exhibiting a level of agitation that meets or exceeds a threshold score of ≥14 on the 5 items comprising the Positive and Negative Syndrome Scale (PANSS) Excited Component.
• Important safety information:
  • Olanzapine for injection is not approved for elderly patients with dementia-related psychosis.
  • Patients and caregivers should be advised that elderly patients with dementia-related psychosis treated with olanzapine for injection had a significantly higher incidence of cerebrovascular adverse events (e.g., stroke, transient ischemic attack) compared with placebo.
  • A potentially fatal symptom complex sometimes referred to as Neuroleptic Malignant Syndrome (NMS) has been reported in association with administration of antipsychotic drugs, including olanzapine for injection.

From the Research

Management of Acute Psychotic Episode

To manage an acute psychotic episode, several key steps and considerations should be taken into account:

• Assessment and Risk Evaluation: The first step is to establish a therapeutic alliance, enabling history, examination, and investigations to assess the patient's condition and risk to themselves or others 3.
• Treatment Goals: Rapid stabilization of intense positive symptoms, hostility, and agitation is typically a preeminent therapeutic goal in the inpatient setting 4.
• Medication Options: Several antipsychotic medications have been found effective in managing acute psychosis, including:
  • Haloperidol: A traditional option, but associated with a higher risk of extrapyramidal symptoms 5, 6.
  • Risperidone: An atypical antipsychotic that has been shown to be as effective as haloperidol with better tolerability 7, 5, 6.
  • Olanzapine: Also an atypical antipsychotic, effective with a different side effect profile, including more weight gain 5, 6.
  • Quetiapine: Another atypical antipsychotic that has been found effective in treating psychotic agitation with good tolerability 5.
• Treatment Approach: The choice of antipsychotic should consider efficacy against positive symptoms, speed of therapeutic onset, and the patient's ability to tolerate the medication 4. Oral treatment with risperidone plus lorazepam has been found to be as effective as intramuscular treatment with haloperidol plus lorazepam for rapid control of agitation and psychosis 7.
• Community vs. Inpatient Care: The decision to manage the patient in the community or in an inpatient setting depends on the risk assessment and the patient's specific needs 3.