Management of Acute Psychosis
The optimal management of acute psychosis requires prompt initiation of atypical antipsychotics as first-line treatment, with medication selection based on side-effect profiles and patient characteristics, alongside comprehensive psychosocial interventions. 1
Initial Assessment and Intervention
Rule Out Secondary Causes
- Evaluate for medical conditions that can present with psychotic symptoms:
Medication Management
First-Line Treatment
- Atypical antipsychotics are 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 Acutely Agitated Patients
- Immediate intervention options:
- Benzodiazepines (lorazepam or midazolam)
- Conventional antipsychotics (haloperidol) 1
- For cooperative but agitated patients:
- Combination of oral benzodiazepine (lorazepam) and oral antipsychotic (risperidone) 1
Important Medication Considerations
- Allow 4-6 weeks at therapeutic doses before determining efficacy 1
- Avoid large initial doses as they don't hasten recovery but increase side effects 1
- Monitor for serious side effects:
Psychosocial Interventions
Family Support
- Progressively inform and educate families about:
- Provide emotional support and practical advice 2, 1
- Develop a supportive crisis plan with the family 1
- Consider multi-family groups with psychoeducation focus 2
Therapeutic Approaches
- Implement supportive psychotherapy with active problem-solving orientation 2, 1
- Focus on finding meaning and developing mastery of the psychotic experience 2, 1
- Facilitate occupational pursuits, including employment and education 2, 1
- Address comorbidities:
Monitoring and Treatment Adjustment
Regular Monitoring
- Daily assessment of:
- Sedation
- Extrapyramidal symptoms
- Behavioral changes 1
- Weekly assessment of:
- Clinical improvement
- Side effects 1
- Discuss early warning signs of relapse with patient and family 2
Treatment Adjustment
- If significant positive symptoms persist after 4 weeks of therapeutic dosing with good adherence, switch to an alternative antipsychotic with a different pharmacodynamic profile 1
- Consider clozapine if schizophrenia diagnosis is confirmed and positive symptoms remain significant after two adequate antipsychotic trials (including at least one atypical agent) 1
- Once psychosis has achieved sustained remission, slow reduction of antipsychotic medication should be tried to determine minimal effective dose 2
- Long-term medication is advisable for individuals who experience frequent relapses 2
Common Pitfalls to Avoid
- Missing secondary causes of psychosis - Always rule out medical conditions before attributing to primary psychiatric disorder 2, 1
- Premature discontinuation - Approximately 65% of patients relapse within 1 year without antipsychotics compared to 30% on medication 1
- Inadequate trial duration - Full 4-6 week trial at therapeutic doses is necessary before determining efficacy 1
- Excessive initial dosing - Large doses during early treatment generally don't hasten recovery but increase side effects 1
- Neglecting family involvement - Families need ongoing support and information in a partnership that involves the patient, family members, and treating clinicians 2
- Failing to monitor for metabolic changes - Regular monitoring for weight gain, hyperglycemia, and dyslipidemia is essential 3, 4
By following this comprehensive approach to managing acute psychosis, clinicians can effectively address both immediate symptoms and long-term recovery, while minimizing risks and complications.