What is the treatment for named delusions?

Treatment of Named Delusions

Delusions, whether occurring as part of primary psychotic disorders or secondary to medical conditions, should be treated with antipsychotic medications—specifically atypical antipsychotics as first-line agents—combined with treatment of any underlying reversible causes. 1, 2

Initial Assessment and Identification of Reversible Causes

Before initiating antipsychotic therapy, conduct a systematic evaluation to identify and treat underlying medical conditions that may be causing or contributing to the delusions:

• Laboratory investigations should include electrolytes (sodium, potassium, calcium, magnesium), renal function (BUN, creatinine), infection markers (WBC count, cultures), glucose, and liver function tests 2
• Screen for specific reversible causes including hypercalcemia, SIADH, hypomagnesemia, infections (particularly urinary tract infections and pneumonia), medication effects or withdrawal, and opioid toxicity 1, 2, 3
• Evaluate for delirium as a primary cause, since delusions can be a cardinal feature of delirium and require different management approaches 1

Pharmacological Management

First-Line Treatment: Atypical Antipsychotics

For delusions with psychotic features causing distress, atypical antipsychotics are the appropriate first-line pharmacological treatment:

• Olanzapine 2.5-15 mg daily offers benefit in managing delusions and is less likely to cause extrapyramidal side effects 1, 3, 4
• Quetiapine 50-100 mg twice daily may offer benefit with fewer side effects, though available only in oral formulations 1, 3
• Aripiprazole may offer benefit and is available in parenteral or orally dispersible formulations in some countries 1
• Risperidone 0.5-1 mg twice daily is an alternative option 3

Second-Line Options

• Haloperidol 0.5-2 mg can be used for severe cases, though it carries higher risk of extrapyramidal side effects 1, 3
• Combination pharmacotherapy should be considered only after two different trials with two different classes of agents at sufficient doses have failed 1

Treatment of Specific Underlying Causes

When delusions are secondary to identifiable medical conditions, address these directly:

• For opioid-induced delusions: Rotate to fentanyl or methadone with a 30-50% reduction in equianalgesic dose 1, 2, 3
• For hypercalcemia-related delusions: Administer IV bisphosphonates (pamidronate or zoledronic acid) 2, 3
• For SIADH-related delusions: Discontinue implicated medications, restrict fluids, and ensure adequate oral salt intake 2, 3
• For medication-induced delusions: Withdraw offending medications, particularly those with anticholinergic properties 3

Non-Pharmacological Interventions

Maximize non-pharmacological strategies before or alongside medication use:

• Environmental modifications including reorientation, quiet environment, and optimization of day-night rhythm 2
• Sensory optimization by ensuring glasses and hearing aids are available 2
• Cognitive stimulation through frequent reorientation by familiar caregivers 2
• Cognitive behavioral therapy (CBT) has shown promise for delusional disorders, though it requires tailoring to individual needs and combining multiple strategies 5

Duration and Monitoring

• Use the lowest effective dose for the shortest duration necessary to control symptoms 1, 2
• Evaluate for tapering or discontinuation no more than 6 months after symptoms stabilize, with attempts at tapering every 6 months thereafter 1
• Reassess systematically over time, as continued follow-up may be necessary to distinguish primary psychotic disorders from mood disorders with psychotic features 1

Critical Pitfalls to Avoid

• Do not use haloperidol or risperidone for mild-to-moderate delusions in the context of delirium, as they have no demonstrable benefit and may worsen symptoms 1, 3
• Avoid benzodiazepines as initial treatment unless delusions are due to alcohol or benzodiazepine withdrawal, as they can worsen delirium and increase fall risk 1, 3
• Do not overlook hypoactive presentations where delusions may be present but less obvious due to withdrawal and diminished expression 3
• Distinguish between primary and secondary causes through comprehensive evaluation, as this fundamentally changes the treatment approach 1, 4