What medications are used in the psychiatric ward?

Medications Used in Psychiatric Wards

Psychiatric wards primarily utilize atypical antipsychotics (risperidone, olanzapine, quetiapine, ziprasidone) as first-line agents for psychosis and agitation, with haloperidol reserved for situations where atypicals are unavailable or cost-prohibitive, and benzodiazepines (lorazepam) used adjunctively for acute agitation. 1

First-Line Medications for Psychosis

Atypical Antipsychotics (Preferred)

• Risperidone is initiated at 0.5-1 mg daily with target doses of 2 mg/day for most patients, offering efficacy with better tolerability than typical antipsychotics 1
• Olanzapine can be started at 2.5 mg daily at bedtime (maximum 10 mg/day in divided doses), demonstrating the least QTc prolongation (only 2 ms) among antipsychotics, making it the safest cardiac option 1
• Quetiapine is initiated at 12.5 mg twice daily (maximum 200 mg twice daily), though it is more sedating with risk of transient orthostasis 1
• Ziprasidone 20 mg IM rapidly reduces acute agitation with notably absent extrapyramidal symptoms and dystonia 1

Typical Antipsychotics (Second-Line)

• Haloperidol should only be routinely offered as first-line treatment when atypical antipsychotics cannot be assured or are cost-prohibitive, according to WHO recommendations 1
• For first-episode psychosis, haloperidol 2 mg daily is effective for many patients, with doses rarely needing to exceed 5 mg daily 2, 3
• Haloperidol carries higher risk of extrapyramidal symptoms (7 ms QTc prolongation vs. 2 ms for olanzapine) and movement disorders that severely impact future medication adherence 1

Acute Agitation Management

For Cooperative Patients

• Oral olanzapine 2.5-5 mg is the preferred first-line agent, with option to repeat after 2 hours if needed 1
• Combination therapy with oral risperidone plus lorazepam 2 mg produces similar improvement to haloperidol plus lorazepam in cooperative agitated patients 1

For Non-Cooperative/Severely Agitated Patients

• Olanzapine 10 mg IM for non-cooperative patients provides rapid tranquilization with minimal cardiac effects 1, 4
• Haloperidol 5 mg plus lorazepam 2-4 mg IM produces significantly greater reduction in agitation compared to either agent alone, with combination therapy requiring fewer repeat doses 5, 6
• Haloperidol 5 mg plus promethazine 25-50 mg combines the sedative properties of the antihistamine with the calming action of haloperidol while reducing extrapyramidal effects through promethazine's anticholinergic properties 5, 7
• Benzodiazepines provide more rapid sedation (within 15-30 minutes) while haloperidol's antipsychotic effect becomes more apparent after 1-2 weeks 6

Medications to Avoid When Over-Sedation is a Concern

• Benzodiazepines cause dose-dependent CNS depression with unpredictable duration and have a 10% rate of paradoxical agitation, particularly in elderly patients and younger children 1
• Olanzapine 2.5 mg orally is preferred when minimizing sedation risk, as patients over 50 years have more profound sedation with all agents 1

Special Population Considerations

Cardiac Disease/Cardiomyopathy

• Olanzapine is the safest antipsychotic with only 2 ms mean QTc prolongation compared to haloperidol's 7 ms 1
• Thioridazine should be avoided due to significant QTc prolongation (25-30 ms) 1
• Obtain baseline ECG if cardiac risk factors are present, as both typical and atypical antipsychotics can prolong QTc interval 1

Elderly/Dementia-Related Agitation

• Risperidone 0.25 mg daily at bedtime (maximum 2-3 mg/day in divided doses), though extrapyramidal symptoms may occur at doses ≥2 mg/day 1
• Olanzapine 2.5 mg daily at bedtime for elderly or medically compromised patients 1

Parkinson's Disease or Lewy Body Dementia

• Avoid haloperidol entirely due to severe extrapyramidal symptom risk 1
• Use quetiapine or clozapine as safer alternatives in these populations

Critical Safety Monitoring

Extrapyramidal Symptoms

• Have diphenhydramine or benztropine immediately available for acute dystonic reactions with haloperidol 6
• Monitor for extrapyramidal symptoms at every visit, as these predict poor long-term adherence 1
• Haloperidol carries 11 times higher risk of side effects compared to lorazepam 5

Cardiac Monitoring

• Baseline ECG recommended for patients with cardiac risk factors before initiating any antipsychotic 1
• Droperidol carries FDA black box warning regarding potential dysrhythmias 1

Long-Term Risks

• Tardive dyskinesia can develop in up to 50% of patients after 2 years of continuous typical antipsychotic use 6
• Monitor for neuroleptic malignant syndrome (hyperpyrexia, muscle rigidity, altered mental status, autonomic instability) requiring immediate haloperidol discontinuation 6

Dosing Duration and Adjustment

• Maintain therapeutic haloperidol doses for at least 4-6 weeks to properly assess efficacy, as immediate effects are primarily sedation rather than true antipsychotic response 6
• Avoid increasing to large doses during early treatment, as this typically results in excessive dosing and side effects without hastening recovery 6
• If positive symptoms persist after 4 weeks at therapeutic doses with confirmed adherence, switch to an atypical antipsychotic such as risperidone (2 mg/day), olanzapine (7.5-10 mg/day), or quetiapine 6