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

Initial Treatment of Acute Psychosis

The recommended initial treatment for a patient presenting with acute psychosis is an atypical antipsychotic, specifically risperidone 2 mg/day or olanzapine 7.5-10.0 mg/day, which should be provided in outpatient settings or at home when possible. 1

Initial Assessment

• Before initiating treatment, rule out physical illnesses that can cause psychosis 1, 2
• Assess risk of self-harm or aggression to determine appropriate treatment setting 2
• Evaluate level of community support and family's ability to manage the crisis 1

Pharmacological Management

First-Line Treatment

• Atypical antipsychotics are preferred due to better tolerability and improved adherence 1, 2
• Recommended initial target doses:
  • Risperidone 2 mg/day 1
  • Olanzapine 7.5-10.0 mg/day 1
• Avoid excessive initial dosing as it doesn't hasten recovery but increases side effects 2

Administration Considerations

• Treatment should be implemented for 4-6 weeks using adequate dosages before determining efficacy 2
• Antipsychotic effects typically become apparent after 1-2 weeks, with any immediate effects likely due to sedation 2
• Risperidone has shown a shorter onset of action compared to olanzapine and haloperidol 3

Adjunctive Medication

• Short-term use of benzodiazepines as adjuncts to antipsychotics may help stabilize the acute situation 2
• For agitated but cooperative patients, a combination of oral benzodiazepine (lorazepam) and oral antipsychotic (risperidone) can be effective 1

Treatment Setting

• Provide treatment in outpatient services or at home when possible 1
• In-patient care may be required if:
  • Significant risk of self-harm or aggression exists 1
  • Level of community support is insufficient 1
  • Degree of crisis is too great for the family to manage 1

Psychosocial Interventions

• Include families in the assessment process and treatment planning 1
• Develop supportive crisis plans to facilitate recovery and treatment acceptance 1
• Provide emotional support and practical advice to families, who are usually in crisis at the point of treatment initiation 1

Follow-up and Monitoring

• Monitor for extrapyramidal side effects, which should be avoided to encourage future medication adherence 1
• If positive psychotic symptoms persist after a trial of two first-line atypical antipsychotics (around 12 weeks), review reasons for treatment failure 1
• Ensure continuity of care with treating clinicians remaining constant for at least the first 18 months of treatment 1

Common Pitfalls to Avoid

• Avoid typical antipsychotics as first-line treatment: Although they may be as efficacious as atypical antipsychotics in reducing positive psychotic symptoms, they are less well tolerated even at low doses 1
• Avoid excessive initial dosing: Large initial doses don't hasten recovery but increase side effects 2
• Don't switch medications too early: Allow 4-6 weeks before determining efficacy 2
• Don't neglect family support: Families require emotional support and practical advice during this crisis period 1

Special Considerations

• For severely agitated patients requiring rapid sedation, consider droperidol instead of haloperidol 1
• Fast orally disintegrating risperidone tablets have shown effectiveness in initial treatment of acutely ill psychotic patients, with a median time to calmness of 70 minutes 4
• Individual responses to different antipsychotics are variable, so monitoring and adjustment may be necessary 2