What are the causes of psychosis?

From the Guidelines

Psychosis is a serious mental health condition that requires immediate attention, and treatment usually involves antipsychotic medications such as risperidone (2-6mg daily), olanzapine (5-20mg daily), or aripiprazole (10-30mg daily), combined with psychotherapy, as recommended by the American Psychiatric Association 1.

Key Considerations

• The initial assessment of a patient with a possible psychotic disorder should include a review of psychiatric symptoms and trauma history, an assessment of tobacco use and other substance use, a psychiatric treatment history, an assessment of physical health, and an assessment of psychosocial and cultural factors, as outlined in the APA’s Practice Guidelines for the Psychiatric Evaluation of Adults 1.
• Patients with schizophrenia should have a documented, comprehensive, and person-centered treatment plan that includes evidence-based nonpharmacological and pharmacological treatments, and APA recommends (1A) that patients with schizophrenia be treated with an antipsychotic medication and monitored for effectiveness and side effects 1.
• For acute psychosis, hospitalization may be necessary, and first-generation antipsychotics like haloperidol work primarily by blocking dopamine D2 receptors, while second-generation medications like quetiapine also affect serotonin receptors, potentially causing fewer movement-related side effects.
• Treatment typically continues for at least 1-2 years after the first episode, and longer for recurrent episodes, and early intervention significantly improves outcomes, as supported by the international clinical practice guidelines for early psychosis 1.

Psychosocial Interventions

• APA recommends (1B) that patients with schizophrenia who are experiencing a first episode of psychosis be treated in a coordinated specialty care program, and that patients with schizophrenia be treated with cognitive-behavioral therapy for psychosis (CBTp), receive psychoeducation, and receive supported employment services 1.
• Family interventions and social skills training may also be beneficial for patients with schizophrenia, and supportive psychotherapy can be used to manage the crises that face patients and families who are attempting to cope with a disturbing situation 1.

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The treatment of psychosis should be tailored to the individual patient's needs, and the patient's family and social network should be involved in the treatment process, as supported by the ACR Appropriateness Criteria for altered mental status, coma, delirium, and psychosis 1. Some of the key factors that influence the treatment of psychosis include the patient's age, medical history, and substance use history, and the treatment plan should be regularly reviewed and updated to ensure that it remains effective, as recommended by the APA and other clinical guidelines 1. Overall, the treatment of psychosis requires a comprehensive and multidisciplinary approach that takes into account the patient's physical, emotional, and social needs, and the patient's family and social network should be involved in the treatment process to ensure the best possible outcomes, as supported by the clinical guidelines and evidence-based practices 1.

From the Research

Definition and Causes of Psychosis

• Psychosis is a mental state of dysfunction in behavior and thought processes, where mental capacity is grossly distorted and thought is disorganized 2.
• A medical cause is found in approximately 20% of patients with acute psychosis, and emergency medicine physicians must differentiate psychotic symptoms caused by general medical conditions from psychosis caused by a primary psychiatric disorder 2.

Treatment of Acute Psychosis

• Early intervention may be valuable in treating and managing acute psychosis in patients with schizophrenia, but the need to quickly control severe symptoms must be balanced with a treatment algorithm that is both safe and effective 3.
• The treatment of acute psychotic agitation varies among clinicians, with key goals including calming the agitated patient, minimizing danger to self and others, and achieving a smooth transition from intramuscular to oral maintenance 3.
• Intramuscular treatment with benzodiazepines and/or conventional antipsychotics, such as haloperidol, has been the mainstay of treatment for acute psychosis, but the poor tolerability of conventional antipsychotics compromises their usefulness for both short- and long-term treatment 3.

Comparison of Antipsychotic Treatments

• New antipsychotics, such as olanzapine, risperidone, and quetiapine, have a more favorable side-effect profile compared to conventional antipsychotics, and may be as effective as haloperidol in the treatment of psychotic agitation 4.
• A 3-year follow-up study found that olanzapine, risperidone, and aripiprazole presented advantages for the first-line treatment of first episode of psychosis in terms of effectiveness, with significant differences in treatment discontinuation rates and side effects among treatment groups 5.
• The development of intramuscular formulations of olanzapine and ziprasidone offers new treatment options for patients experiencing acute psychotic episodes 3.

Treatment Goals and Guidelines

• Rapid stabilization of intense positive symptoms, hostility, and agitation is typically a preeminent therapeutic goal in the treatment of acute psychosis, particularly in hospitalized patients 6.
• Selection of antipsychotic treatment in the inpatient setting should establish a definitive treatment that will address long-term goals effectively after discharge, including improvement of negative symptoms, cognitive function, compliance, and reduction in side effect burden 6.