What is the treatment for acute psychosis?

Treatment of Acute Psychosis

The treatment of acute psychosis involves pharmacologic management with antipsychotic medications, psychological therapy, and psychosocial interventions, with the specific approach determined by whether the psychosis is primary or secondary in nature. 1

Initial Assessment

• Rule out secondary causes of psychosis before initiating psychiatric treatment, including medical conditions such as endocrine disorders, autoimmune diseases, neoplasms, neurologic disorders, infections, genetic/metabolic disorders, nutritional deficiencies, and drug-related issues 1, 2
• Perform neuroimaging in patients with new-onset psychosis to exclude intracranial processes requiring intervention 1, 2
• Evaluate for risk of self-harm or aggression to determine appropriate treatment setting 1, 2
• Assess level of community support and family's ability to manage the crisis 1, 2

Treatment Approach Based on Etiology

Secondary Psychosis

• Treatment should be aimed at the underlying medical cause while controlling psychotic symptoms 1
• Psychosis associated with substance use typically resolves within 30 days of abstinence from the substance 3

Primary Psychosis

• Begin antipsychotic treatment for patients who have experienced psychotic symptoms for a week or more with associated distress or functional impairment 2
• Use atypical (second-generation) antipsychotics as first-line treatment due to better tolerability 1, 2

Pharmacological Management

Medication Selection and Dosing

• Recommended initial target doses for most patients 1:
  • Risperidone 2 mg/day
  • Olanzapine 7.5–10.0 mg/day
• Avoid extrapyramidal side effects to encourage future medication adherence 1
• If positive symptoms persist after trials of two first-line atypical antipsychotics (approximately 12 weeks), review reasons for treatment failure 1
• For acute agitation, consider intramuscular formulations of olanzapine or ziprasidone 4
• Higher potency antipsychotics like olanzapine, risperidone, and haloperidol may be more effective in acute psychosis for rapid symptom control 5

Treatment Setting

• Provide treatment in outpatient services or home settings when possible 1
• Consider inpatient care if there is significant risk of self-harm or aggression, insufficient community support, or if the crisis is too severe for the family to manage 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 at the point of treatment initiation 1
• Develop supportive crisis plans to facilitate recovery and treatment acceptance 1, 2
• Progressively inform and educate family members and other social network members 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, 2
• Monitor for relapses, which are common during the first few years after onset 1, 2
• Consider transitioning to medications with fewer side effects (metabolic syndrome, extrapyramidal symptoms, hyperprolactinemia) for long-term maintenance once acute symptoms are controlled 5
• Provide ongoing support and information to families in a partnership involving the patient, family members, and treating clinicians 1

Common Pitfalls and Caveats

• Failing to rule out medical causes of psychosis before initiating psychiatric treatment 1
• Using typical antipsychotics as first-line treatment, which may be equally efficacious for positive symptoms but are less well tolerated even at low doses 1
• Delaying treatment until a crisis develops (self-harm, violence, aggression) 1
• Inadequate family involvement and support during treatment 1, 2
• Discontinuing treatment too early, as vulnerability to relapse persists in about 80% of patients 1