What is the initial evaluation and treatment approach for acute psychosis?

Evaluation and Treatment of Acute Psychosis

The initial evaluation of acute psychosis should include a focused medical assessment based on history and physical examination to rule out secondary causes, followed by treatment with low-dose atypical antipsychotics such as risperidone 2 mg/day or olanzapine 7.5-10 mg/day for primary psychosis. 1

Initial Evaluation

Medical Assessment

• Rule out secondary causes first:

  • Illicit drug use (most common medical cause of acute psychosis) 2
  • Recent head injury or trauma
  • Seizures
  • Cerebrovascular disease
  • New or worsening headaches
  • Subacute onset (raises suspicion for oncologic cause) 2

• Physical examination:

  • Complete neurologic assessment
  • Mental status examination
  • Vital signs (tachycardia/hypertension may indicate drug toxicity or thyrotoxicosis; fever may suggest encephalitis) 2

• Laboratory testing:

  • Complete blood count
  • Metabolic profile
  • Thyroid function tests
  • Urine toxicology
  • Parathyroid hormone, calcium, vitamin B12, folate, and niacin levels
  • Consider HIV and syphilis testing 2

Neuroimaging

• Focused approach rather than routine testing:
  • Brain CT or MRI indicated for:
    • Atypical presentation
    • Abnormal neurological examination
    • First-episode psychosis 3
  • Routine brain CT scans have low yield in young patients with new-onset psychosis 1
  • Consider radiation exposure risks in pediatric patients 1

Treatment Approach

Pharmacological Management

1. Initial Medication Selection:

   • Atypical antipsychotics preferred as first-line due to better tolerability and lower risk of extrapyramidal side effects 1, 3
   • Recommended initial doses:
     • Risperidone 2 mg/day OR
     • Olanzapine 7.5-10 mg/day 1

2. For Acute Agitation:

   • Intramuscular medication may be needed for prompt control
   • Haloperidol 2-5 mg IM for severely agitated patients 4
   • Can be administered as often as hourly if needed, though 4-8 hour intervals are often sufficient 4
   • Switch to oral medication as soon as practicable 4, 5

3. Treatment Resistance:

   • If positive symptoms persist after trials of two different atypical antipsychotics (approximately 12 weeks), review reasons for treatment failure 1
   • Consider clozapine after failure of two adequate antipsychotic trials 3

Treatment Setting

• Outpatient or home treatment preferred when possible 1
• Inpatient care indicated for:
  • Significant risk of self-harm or aggression
  • Insufficient community support
  • Crisis too severe for family to manage 1

Psychosocial Interventions

• 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 the problem, treatments, and expected outcomes 1

• Supportive strategies:

  • Develop crisis plans to facilitate recovery and treatment acceptance 1
  • Structured group programs tailored to immediate patient needs 1
  • Consider family therapy when there is high distress in the family 1

Common Pitfalls to Avoid

• Overlooking medical causes of psychotic symptoms 3
• Inadequate dosing or premature discontinuation of medication 3
• Neglecting psychosocial interventions 3
• Using typical antipsychotics that may cause extrapyramidal side effects, leading to poor medication adherence 1
• Routine diagnostic testing without clinical indication (low yield, costly) 1
• Failing to transition from emergency treatment to long-term management 6

Monitoring and Follow-up

• Document target symptoms and treatment response
• Monitor for medication side effects
• Periodically reassess diagnosis, especially in younger patients 3
• Build therapeutic alliance with patient and family for long-term adherence 6
• Plan for maintenance treatment for 1-2 years after initial episode 3

The evaluation and management of acute psychosis requires balancing rapid symptom control with establishing an effective long-term treatment plan. By following this structured approach, clinicians can improve outcomes while minimizing risks associated with both undertreated psychosis and medication side effects.