What is the initial workup and treatment for a patient presenting with acute psychosis?

Initial Workup and Treatment for Acute Psychosis

Before initiating treatment for acute psychosis, it is essential to rule out physical illnesses that can cause psychosis, followed by prompt treatment with low-dose atypical antipsychotics and appropriate psychosocial support. 1

Initial Assessment

Medical Evaluation

• Perform a thorough assessment to rule out secondary causes of psychosis before initiating psychiatric treatment 1
• Consider neuroimaging (CT or MRI) in patients with new-onset psychosis, particularly with atypical presentation, abnormal neurological findings, or unclear clinical picture 1
• Evaluate for potential medical causes including:
  • Central nervous system infections
  • Traumatic brain injury
  • Dementia or other neurological conditions
  • Substance-induced psychosis (will typically resolve within 30 days of abstinence) 2
  • Medication side effects 2

Risk Assessment

• Evaluate for risk of self-harm or aggression to determine appropriate treatment setting 1
• Assess level of community support and family's ability to manage the crisis 1
• Consider inpatient care if there is significant risk of harm, insufficient community support, or if the crisis is too overwhelming for the family 1

Treatment Setting

• Provide treatment in outpatient settings or home whenever possible and safe 1
• Reserve inpatient care for situations with:
  • Significant risk of self-harm or aggression
  • Insufficient community support
  • Crisis too severe for family management 1
• Ideally, inpatient care should be provided in specialized units targeting early psychosis 1

Pharmacological Management

Initial Medication Selection

• Begin antipsychotic treatment for patients who have experienced psychotic symptoms for a week or more with associated distress or functional impairment 1
• Use atypical (second-generation) antipsychotics as first-line treatment due to better tolerability 1
• Recommended initial target doses:
  • Risperidone 2 mg/day 1, 3
  • Olanzapine 7.5-10.0 mg/day 1

Acute Agitation Management

• For prompt control of acute agitation, consider intramuscular medication:
  • Haloperidol 2-5 mg IM for moderately severe to very severe symptoms 4
  • Subsequent doses may be given as often as hourly if needed, though 4-8 hour intervals are often sufficient 4
• Switch to oral medication as soon as practicable 4

Medication Monitoring

• Assess response frequently but increase antipsychotic doses only at widely spaced intervals (14-21 days after initial titration) if response is inadequate 1
• Stay within limits of sedation and avoid extrapyramidal side effects 1
• If positive symptoms persist after trials of two first-line atypical antipsychotics (approximately 12 weeks), review reasons for treatment failure 1

Psychosocial Interventions

• Include families in the assessment process and treatment planning 1
• Provide emotional support and practical advice to families, who are often in crisis 1
• Develop supportive crisis plans to facilitate recovery and treatment acceptance 1
• Implement specific psychosocial strategies to help patients and families cope with the disturbing situation 1
• Progressively inform and educate family members and the patient's social network about the nature of the problem, treatments, and expected outcomes 1

Follow-up Care

• Ensure continuity of care with treating clinicians remaining constant for at least the first 18 months of treatment 1
• Monitor for relapses, which are common during the first few years after onset of psychosis 1
• Consider more intensive and prolonged psychoeducational and supportive interventions for families if there are frequent relapses or slow recovery 1
• Provide structured group programs tailored to the immediate needs of the patient 1

Common Pitfalls to Avoid

• Using excessive doses of antipsychotics in first-episode psychosis (keep haloperidol equivalent to maximum 4-6 mg) 1
• Failing to consider physical illnesses as causes of psychosis 1, 5
• Neglecting family involvement and support 1
• Causing extrapyramidal side effects, which may discourage medication adherence 1
• Delaying treatment until a crisis develops (self-harm, violence, or aggression) 1
• Reactive "too little, too late" care instead of continuous, assertive biopsychosocial care 1