Treatment of Psychosis
The recommended treatment for psychosis is low-dose atypical antipsychotics, specifically starting with risperidone 2 mg/day or olanzapine 7.5-10.0 mg/day, provided in outpatient services or home settings when possible, with concurrent psychosocial interventions and family support. 1
Medication Management
First-Line Pharmacological Treatment
- Initial medication selection:
- Atypical antipsychotics are preferred over typical antipsychotics due to better tolerability and fewer extrapyramidal side effects 1
- Recommended starting doses:
Dosing and Titration
- Start with low doses and titrate slowly
- Dose increases should occur only at widely spaced intervals (14-21 days after initial titration) if response is inadequate 1
- Maximum recommended doses for first-episode psychosis:
Treatment Duration and Monitoring
- Assess response and side effects frequently
- If positive psychotic symptoms persist after trials of two first-line atypical antipsychotics (approximately 12 weeks), review reasons for treatment failure 1
- For treatment-resistant cases (failure of at least two adequate antipsychotic trials of 6+ weeks each), consider clozapine 1
Treatment Setting
Outpatient vs. Inpatient Care
- Treatment should be provided in outpatient services or home settings when possible 1
- Inpatient care may be required if:
- Significant risk of self-harm or aggression exists
- Community support is insufficient
- Family cannot manage the degree of crisis 1
Crisis Management
- Develop supportive crisis plans to facilitate recovery and treatment acceptance 1
- Treatment should ideally commence before crisis development (self-harm, violence, aggression) 1
- When inpatient care is necessary, units should be small and adequately staffed 1
Psychosocial Interventions
Family Involvement
- Include families in assessment and treatment planning 1
- Provide emotional support and practical advice to families, who are often in crisis 1
- Progressively inform and educate family members and the patient's social network about the nature of psychosis, treatments, and expected outcomes 1
- Consider more intensive psychoeducational and supportive interventions for families if there are frequent relapses or slow recovery 1
Structured Support
- Provide structured group programs tailored to immediate patient needs 1
- Consider family therapy when there is high distress within the family 1
- Ensure continuity of care with treating clinicians remaining constant for at least 18 months 1
Special Considerations
First-Episode Psychosis
- Very low doses may be effective and better tolerated in first-episode psychosis 3, 4
- Early intervention has potential to provide safer and more positive treatment initiation 1
- Avoid extrapyramidal side effects to encourage future medication adherence 1
Treatment-Resistant Psychosis
- Defined as failure of at least two adequate antipsychotic trials (each lasting at least 6 weeks at therapeutic doses) 1
- Consider timing of resistance onset: early-onset (within first year), medium-term onset (1-5 years), or late-onset (>5 years) 1
Medical Considerations
- Before initiating treatment, rule out physical illnesses that can cause psychosis 1
- Elderly patients with dementia-related psychosis have increased mortality risk when treated with antipsychotics 5
Common Pitfalls to Avoid
- Using typical antipsychotics as first-line treatment (higher risk of extrapyramidal side effects)
- Starting with doses that are too high, especially in first-episode psychosis or pediatric patients
- Failing to involve and support families in the treatment process
- Increasing doses too rapidly or too frequently
- Not considering physical causes of psychosis before initiating treatment
- Neglecting psychosocial interventions alongside pharmacological treatment