What is the recommended algorithm for managing psychosis?

Algorithm for Managing Psychosis

The management of psychosis should follow a structured approach beginning with atypical antipsychotics at low doses in outpatient or home settings when possible, with careful monitoring for side effects and response. 1

Initial Assessment and Treatment Setting

1. Rule out physical causes of psychosis

   • Consider medical conditions that can cause psychosis before initiating treatment 1
   • Approximately 20% of acute psychosis cases have medical causes 2
   • Evaluate for substance-induced psychosis (will typically resolve within 30 days of abstinence) 3

2. Determine appropriate treatment setting

   • Outpatient/home treatment is preferred when possible 1
   • Inpatient care is indicated when:
     • Significant risk of self-harm or aggression exists
     • Insufficient community support is available
     • Family cannot manage the degree of crisis 1
   • Inpatient units should be small and adequately staffed 1

Medication Selection and Dosing

1. First-line medication: Atypical antipsychotics

   • Preferred over typical antipsychotics due to better tolerability and fewer extrapyramidal side effects 1
   • Initial target doses for adults:
     • Risperidone: 2 mg/day
     • Olanzapine: 7.5-10.0 mg/day 1
   • For children: Much lower doses (e.g., risperidone 0.25 mg daily for a 5-year-old) 4

2. Dose titration

   • Increase doses only at widely spaced intervals (14-21 days after initial titration)
   • Maximum doses for first-episode psychosis:
     • Risperidone: 4 mg/day
     • Olanzapine: 20 mg/day 1
   • Avoid extrapyramidal side effects to encourage medication adherence 1

3. Treatment resistance

   • If positive symptoms persist after trials of two atypical antipsychotics (approximately 12 weeks), review reasons for treatment failure 1
   • Consider clozapine for treatment-refractory cases, with appropriate monitoring 3

Psychosocial Interventions

1. Family involvement

   • Include families in assessment and treatment planning 1
   • Provide emotional support and practical advice to families in crisis 1
   • Progressive education about the nature of psychosis, treatments, and expected outcomes 1
   • More intensive psychoeducation if frequent relapses or slow recovery occur 1

2. Supportive strategies

   • Develop crisis plans to facilitate recovery and treatment acceptance 1
   • Implement specific psychosocial strategies to help patients and families cope 1
   • Structured group programs tailored to immediate patient needs 1

Long-term Management (Critical Period: Up to 5 Years)

1. Continuity of care

   • Maintain consistent treating clinicians for at least 18 months 1
   • Provide high-quality, intensive biopsychosocial care during critical years 1

2. Relapse prevention

   • Monitor for early signs of relapse while allowing space for recovery 1
   • Address depression, suicide risk, substance misuse, and social anxiety 1

3. Medication optimization

   • Monitor side effects regularly (weight gain, sexual dysfunction, sedation)
   • Consider slow reduction of antipsychotic medication after sustained remission 1

4. Recovery support

   • Implement supportive psychotherapy with active problem-solving
   • Focus on finding meaning and developing mastery of the psychotic experience
   • Facilitate occupational pursuits including employment/education 1

Special Considerations

1. Psychosis due to neurological conditions

   • For Alzheimer's disease: First-line risperidone 0.5-3 mg/day; alternatives include low-dose haloperidol, olanzapine, quetiapine, or clozapine 5
   • For Parkinson's disease: First reduce anti-parkinsonian medications if possible; consider low-dose quetiapine or clozapine 5
   • For epilepsy: Maximize anticonvulsant therapy first; consider low-dose atypical antipsychotics 5

2. Medication selection based on symptom profile

   • Some evidence suggests quetiapine may be superior for reducing PANSS scores and improving functioning 6
   • Consider individual side effect profiles when selecting medications 3

3. Caution in special populations

   • Use antipsychotics with caution in older adults and patients with dementia-related psychosis due to mortality risk 3
   • For pediatric patients, use much lower doses and monitor closely for side effects 4