What is the initial management approach for acute psychosis?

Initial Management Approach for Acute Psychosis

The initial management of acute psychosis should include a thorough assessment to rule out secondary causes, followed by treatment with atypical antipsychotics at appropriate initial doses such as risperidone 2 mg/day or olanzapine 7.5-10.0 mg/day, preferably in outpatient settings when safe and feasible. 1, 2

Assessment and Treatment Setting

• Perform a thorough assessment to rule out physical illnesses that can cause psychosis before initiating psychiatric treatment 2, 1
• Consider neuroimaging (preferably MRI) in patients with new-onset psychosis to exclude organic causes 1, 3
• Evaluate for risk of self-harm or aggression to determine the appropriate treatment setting 1
• Provide treatment in outpatient services or home settings when possible and safe 2
• Consider inpatient care when the degree of crisis is too great for the family to manage or when there are safety concerns 2

Pharmacological Management

• Begin antipsychotic treatment for patients who have experienced psychotic symptoms for a week or more with associated distress or functional impairment 1
• Use atypical antipsychotics as first-line treatment due to better tolerability 1
• Recommended initial target doses: risperidone 2 mg/day or olanzapine 7.5-10.0 mg/day 2
• Short-term use of benzodiazepines as adjuncts to antipsychotics may help stabilize the acute situation 1
• Avoid large initial doses as they don't hasten recovery but increase side effects 1
• Expect antipsychotic effects to become apparent after 1-2 weeks (immediate effects are likely due to sedation) 1

Monitoring and Follow-up

• Implement treatment for 4-6 weeks using adequate dosages before determining efficacy 1
• Monitor closely for extrapyramidal side-effects, which should be avoided to encourage future medication adherence 2
• If positive symptoms persist after a trial of an atypical antipsychotic (around 4-6 weeks), review the reasons for treatment failure 2, 1
• If no results after 4-6 weeks or if side effects are unmanageable, switch to a different antipsychotic with a different pharmacodynamic profile 1

Family Involvement and Psychosocial Support

• Include families in the assessment process and treatment planning 2
• Provide emotional support and practical advice to families, who are usually in crisis at the point of treatment initiation 2
• Progressively inform and educate families and other members of the person's social network about the nature of the problem, treatments, and expected outcomes 2
• Ensure continuity of care, with treating clinicians remaining constant for at least the first 18 months of treatment 2, 1

Common Pitfalls to Avoid

• Avoid excessive initial dosing which leads to unnecessary side effects 1
• Don't switch medications too early (before 4-6 weeks) or too late (continuing ineffective treatment) 1
• Don't neglect monitoring for side effects, which are a common reason for medication non-compliance 1
• Avoid abrupt discontinuation of antipsychotics after acute symptom resolution, as maintenance therapy prevents relapse 1
• Don't delay treatment until a crisis develops, such as self-harm, violence, or aggression 2

Special Considerations for Treatment-Resistant Cases

• If positive symptoms remain significant after two adequate treatment trials (at least 4 weeks each), reassess diagnosis and contributing factors 1
• Consider clozapine for treatment-resistant cases, as it's the only antipsychotic with documented superiority for treatment-refractory schizophrenia 1
• 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) 1

Transition to Maintenance Phase

• The recuperative phase occurs after 4-12 weeks if the acute phase is controlled 1
• Maintain antipsychotic medication during this period as additional improvement may occur over 6-12 months 1
• Consider gradual dose reduction to decrease side effects, especially if high doses were needed for acute control 1