What is the recommended treatment for acute psychosis?

Management of Acute Psychosis

For acute psychosis, antipsychotic medication should be offered to individuals who have experienced psychotic symptoms for a week or more with associated distress or functional impairment, with atypical antipsychotics as first-line treatment due to better tolerability. 1

Initial Assessment and Treatment

• Rule out secondary causes of psychosis (CNS infections, traumatic brain injury) before initiating psychiatric treatment 1
• Evaluate for risk of self-harm or aggression to determine appropriate treatment setting 1
• For acutely agitated patients, intramuscular medication can be administered for prompt control:
  • Haloperidol 2-5 mg IM for prompt control of acutely agitated patients with moderately severe to very severe symptoms 2
  • Short-term use of benzodiazepines as adjuncts to antipsychotics may help stabilize the clinical situation 3

Pharmacological Management Algorithm

First-Line Treatment

• Begin antipsychotic therapy at appropriate starting doses:
  • Risperidone 2 mg/day (oral) 1, 4
  • Olanzapine 7.5-10.0 mg/day (oral) 1
• Implement treatment for 4-6 weeks using adequate dosages before determining efficacy 3
• Any immediate effects are likely due to sedation, with antipsychotic effects becoming apparent after 1-2 weeks 3
• Avoid large initial doses as they don't hasten recovery but increase side effects 3

If First Treatment Fails

• If no results after 4-6 weeks or if side effects are unmanageable, switch to a different antipsychotic 3
• When switching antipsychotics, choose a compound with a different pharmacodynamic profile 3
• For patients whose first-line treatment was a D2 partial agonist, consider amisulpride, risperidone, paliperidone, or olanzapine as second-line treatment 3

Treatment-Resistant Cases

• If positive symptoms remain significant after two adequate treatment trials (at least 4 weeks each), reassess diagnosis and contributing factors 3
• Consider clozapine for treatment-resistant cases, as it's the only antipsychotic with documented superiority for treatment-refractory schizophrenia 3
• Clozapine should be used only after failure to respond to at least two therapeutic trials of other antipsychotic agents (at least one being an atypical antipsychotic) 3

Transition from Acute to Maintenance Phase

• Switch from intramuscular to oral medication as soon as practicable 2
• For initial approximation of oral dose, use the parenteral dose administered in preceding 24 hours 2
• Monitor clinical signs and symptoms, efficacy, sedation, and adverse effects during transition 2
• The recuperative phase occurs after 4-12 weeks if the acute phase is controlled 3
• Maintain antipsychotic medication during this period as additional improvement may occur over 6-12 months 3
• Consider gradual dose reduction to decrease side effects, especially if high doses were needed for acute control 3

Special Considerations

• Individual responses to different antipsychotics are variable 3
• Atypical agents may be more effective for negative symptoms 3
• For adolescents, depot antipsychotics should only be considered with documented chronic psychotic symptoms and poor medication compliance 3
• Building a therapeutic alliance with the patient and family is crucial for long-term management 5
• Monitor for side effects carefully, especially in youth where these medications have not been well studied 3

Common Pitfalls to Avoid

• Avoid excessive initial dosing which leads to unnecessary side effects 3
• Don't switch medications too early (before 4-6 weeks) or too late (continuing ineffective treatment) 3
• Don't neglect monitoring for side effects, which are a common reason for medication non-compliance 3
• Avoid abrupt discontinuation of antipsychotics after acute symptom resolution, as maintenance therapy prevents relapse 3
• Don't overlook medical causes of psychosis before initiating psychiatric treatment 1