From the Guidelines
The most effective pharmacological treatment for a patient with psychosis is an antipsychotic medication, with a recommendation to start with a second-generation (atypical) antipsychotic such as risperidone, olanzapine, or aripiprazole, as stated by the American Psychiatric Association practice guideline for the treatment of patients with schizophrenia 1.
Key Considerations
- The initial assessment of a patient with a possible psychotic disorder should include a review of psychiatric symptoms, trauma history, substance use, and physical health, as well as a mental status examination and an assessment of risk of suicide and aggressive behaviors 1.
- The treatment plan should be comprehensive, person-centered, and include evidence-based nonpharmacological and pharmacological treatments, with a focus on reducing morbidity, mortality, and significant psychosocial and health consequences of the condition 1.
- Antipsychotic medication should be monitored for effectiveness and side effects, and patients whose symptoms have improved with an antipsychotic medication should continue to be treated with an antipsychotic medication, with consideration of long-acting injectable formulations for patients with adherence difficulties 1.
Medication Selection
- The selection of antipsychotic medication should consider the patient's specific symptom profile, medical history, and previous medication responses, with a focus on minimizing side effects and maximizing therapeutic response 1.
- Clozapine is recommended for patients with treatment-resistant schizophrenia, or for patients with a substantial risk of suicide attempts or suicide, despite other treatments 1.
- Regular monitoring for metabolic side effects, extrapyramidal symptoms, and prolactin elevation is essential, as well as consideration of psychosocial interventions, such as cognitive-behavioral therapy for psychosis, psychoeducation, and supported employment services 1.
Comparison with Other Guidelines
- The international clinical practice guidelines for early psychosis also recommend starting with a second-generation (atypical) antipsychotic, such as risperidone or olanzapine, with a focus on minimizing side effects and maximizing therapeutic response 1.
- However, the American Psychiatric Association practice guideline for the treatment of patients with schizophrenia is more recent and comprehensive, and provides a more detailed and person-centered approach to treatment 1.
From the FDA Drug Label
The efficacy of RISPERIDONE in the treatment of schizophrenia was established in four short term (4- to 8-week) controlled trials of psychotic inpatients who met DSM-III-R criteria for schizophrenia The most consistently positive responses on all measures were seen for the 6 mg dose group, and there was no suggestion of increased benefit from larger doses The most consistently positive responses were seen for the 4 mg dose group In an 8-week, dose comparison trial (n=1356) involving 5 fixed doses of RISPERIDONE (1 mg/day, 4 mg/day, 8 mg/day, 12 mg/day, and 16 mg/day, on a twice-daily schedule), the four highest RISPERIDONE dose groups were generally superior to the 1 mg RISPERIDONE dose group on BPRS total score, BPRS psychosis cluster, and CGI severity score
The most effective pharmacological treatment for a patient with psychosis is Risperidone (PO) at a dose of 4-6 mg/day 2.
- Key benefits:
- Established efficacy in short-term controlled trials
- Consistently positive responses on multiple measures
- No suggestion of increased benefit from larger doses
- Recommended dosage: 4-6 mg/day, with a twice-daily schedule.
From the Research
Effective Pharmacological Treatments for Psychosis
The most effective pharmacological treatment for a patient with psychosis can depend on various factors, including the specific symptoms, patient history, and potential side effects.
- Studies have shown that antipsychotic medications such as olanzapine, risperidone, and haloperidol can be effective in reducing psychotic symptoms 3, 4.
- A study comparing haloperidol, risperidone, and olanzapine found that all three treatments showed similar effectiveness in reducing the severity of general, negative, and positive symptomatology after 6 weeks of treatment 3.
- Another study found that olanzapine, amisulpride, and clozapine had the strongest evidence indicating greater efficacy for treating primary negative symptoms relative to other antipsychotics 5.
- In terms of side effects, clozapine and olanzapine have among the highest weight gain potential, while sertindole and amisulpride have more effects on QTc prolongation than other commonly used antipsychotics 5.
Considerations for Treatment
When selecting an antipsychotic medication, considerations should include the clinical situation, preferred route of administration, pharmacokinetic profile of the antipsychotic, and the medications currently being taken by the patient 6.
- Intramuscular preparations are usually preferred over oral medication when patients are not cooperative and require drugs with a faster onset of action and good bioavailability 6, 7.
- High potency antipsychotics such as haloperidol and fluphenazine are effective in stabilizing patients with psychotic symptoms quickly, while loxapine is an alternative when sedation is necessary 6.
- The development of intramuscular formulations of olanzapine and ziprasidone offers new treatment options for patients experiencing acute psychotic episodes 7.
Treatment Goals
The key treatment goals for acute psychosis are to calm the agitated patient, minimize the danger to self and others, and achieve a smooth transition from intramuscular to oral maintenance 7.