What is the best medication for acute psychosis in the emergency department?

Best Medication for Acute Psychosis in Emergency Department

Risperidone 2 mg orally with lorazepam 2-2.5 mg orally is the best medication regimen for acute psychosis in the emergency department, as it is at least as effective as intramuscular conventional neuroleptics while causing fewer extrapyramidal side effects. 1

First-Line Treatment Options

Oral Medication Approach

• Oral risperidone plus oral lorazepam is recommended as first-line treatment for acute psychosis in the emergency department:
  • Initial dose: Risperidone 2 mg orally + Lorazepam 2-2.5 mg orally 2, 1
  • This combination has been shown to be at least as effective as intramuscular conventional neuroleptics with a success rate of 66.9% at 2 hours 1
  • Significantly lower incidence of extrapyramidal symptoms (1.7%) compared to intramuscular conventional neuroleptics (9.5%) 1

Intramuscular Option (if oral not feasible)

• If oral medication is not feasible due to severe agitation or refusal:
  • Haloperidol 2-5 mg intramuscularly for prompt control of acutely agitated patients 3
  • May be repeated as often as every hour if needed, though 4-8 hour intervals are typically sufficient 3

Dosing Considerations

Risperidone Dosing

• Initial target dose for most patients: 2 mg/day 2
• Can be titrated up to 4-6 mg/day if needed, but doses higher than 3 mg/day have not shown greater efficacy in acute settings 4
• Avoid rapid dose escalation to minimize side effects 4

Special Populations

• For debilitated or geriatric patients:
  • Lower doses are recommended
  • More gradual dose adjustments
  • Higher risk of adverse effects 3

Monitoring and Follow-up

• Monitor clinical signs and symptoms closely during the first several days:

  • Clinical efficacy
  • Sedation levels
  • Adverse effects, particularly extrapyramidal symptoms 4, 3

• Transition to oral maintenance therapy as soon as practicable:

  • Continue with risperidone at appropriate maintenance dose
  • Gradually taper lorazepam as symptoms stabilize 3

Advantages of Recommended Approach

• Oral risperidone plus lorazepam:
  • Rapidly reduces symptoms, including aggression 1
  • Avoids traumatic injections which may damage therapeutic alliance
  • Lower risk of extrapyramidal symptoms compared to conventional antipsychotics 2, 1
  • Provides smoother transition to maintenance therapy 5

Potential Pitfalls and Caveats

• Extrapyramidal side effects should be avoided to encourage future medication adherence 2
• Conventional antipsychotics, while efficacious for positive symptoms, are less well tolerated even at low doses 2
• Before initiating treatment, consider physical illnesses that can cause psychosis 2
• If oral administration is not possible due to severe agitation or refusal, intramuscular options may be necessary 3, 6

This evidence-based approach balances rapid symptom control with minimizing side effects, improving the likelihood of continued treatment adherence and better long-term outcomes for patients experiencing acute psychosis.