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

Best Medication for Acute Psychosis in Emergency Department

For acute psychosis in the emergency department, oral risperidone 2 mg plus oral lorazepam 2-2.5 mg is the recommended first-line treatment, as it is at least as effective as intramuscular conventional neuroleptics while causing fewer extrapyramidal side effects. 1

Medication Selection Algorithm

First-Line Treatment

1. Oral medication combination:
   • Risperidone 2 mg orally 2, 1
   • Plus lorazepam 2-2.5 mg orally 1

Alternative Options (if oral medication is not feasible)

1. Intramuscular options:
   • Haloperidol 2-5 mg IM 3
   • Consider adding lorazepam 1-2 mg IM 4

Rationale for Recommendation

Efficacy

• Oral risperidone plus oral lorazepam has been shown to be at least as effective as intramuscular conventional neuroleptics in the emergency treatment of acute psychosis, with a higher success rate at 2 hours (66.9% vs 54.3%) 1
• Risperidone demonstrates a shorter onset of action for treating acute psychotic symptoms compared to olanzapine, haloperidol, and thiothixene 5

Safety Profile

• The combination of oral risperidone and lorazepam causes significantly fewer extrapyramidal symptoms (1.7%) compared to standard intramuscular care (9.5%) 1
• Atypical antipsychotics like risperidone are generally better tolerated than conventional antipsychotics 2, 4

Dosing Considerations

• Initial target doses for most patients with psychosis are risperidone 2 mg/day 2
• For rapid control of acute agitation, risperidone 2 mg combined with lorazepam 2-2.5 mg provides effective symptom reduction 1

Important Clinical Considerations

Patient Assessment

• Before initiating treatment, rule out physical illnesses that can cause psychosis 2
• Assess for risk of self-harm or aggression to determine if inpatient care is required 2

Administration Considerations

• If the patient refuses oral medication or is too agitated to cooperate, intramuscular options may be necessary
• Haloperidol 2-5 mg IM can be utilized for prompt control of acutely agitated patients with moderately severe to very severe symptoms 3

Monitoring

• After initial medication administration, monitor clinical signs and symptoms including:
  • Clinical efficacy
  • Sedation level
  • Adverse effects, particularly extrapyramidal symptoms
  • Vital signs

Transition to Maintenance

• An oral form should replace injectable medication as soon as practicable 3
• For patients initially treated with IM medication, the first oral dose should be given within 12-24 hours following the last parenteral dose 3

Common Pitfalls to Avoid

1. Excessive dosing: Starting with too high a dose increases the risk of side effects without necessarily improving efficacy
2. Neglecting physical causes: Failing to consider medical causes of acute psychosis before initiating antipsychotic treatment
3. Inadequate monitoring: Not monitoring for extrapyramidal side effects after administration
4. Overlooking patient preference: When possible, offering oral medication options can improve treatment adherence and patient experience

By following this approach, clinicians can effectively manage acute psychosis in the emergency department while minimizing adverse effects and optimizing treatment outcomes.