What are the indications for hospitalizing a patient with psychosis?

From the Guidelines

Hospitalization for a patient with psychosis is necessary when they present an immediate danger to themselves or others, or when they cannot safely care for their basic needs, as recommended by the American Psychiatric Association practice guideline for the treatment of patients with schizophrenia 1. When determining the need for hospitalization, look for specific warning signs including:

• Suicidal or homicidal thoughts with a plan
• Severe self-neglect (not eating or drinking)
• Inability to care for themselves
• Aggressive behavior
• Psychotic symptoms that severely impair functioning Rapid deterioration of mental status or failure to respond to outpatient treatment also warrants hospitalization. The decision should consider the severity of symptoms, available support systems, and treatment compliance, as outlined in the assessment and determination of treatment plan section of the guideline 1. Hospitalization provides intensive monitoring, medication adjustment (such as starting antipsychotics like risperidone 0.5-2mg, olanzapine 5-10mg, or haloperidol 2-5mg daily), and a safe environment for stabilization. Many regions have involuntary commitment laws that allow for hospitalization without consent when a person poses a danger due to mental illness. The goal is always to use the least restrictive environment that can safely manage the patient's condition, with hospitalization reserved for situations where outpatient management is insufficient to ensure safety and proper treatment, as suggested by international clinical practice guidelines for early psychosis 1. It is essential to provide high-quality and intensive biopsychosocial care continuously and assertively during the critical years after the onset of psychosis, and to ensure continuity of care with ‘treating clinicians’ remaining constant for at least the first 18 months of treatment 1. Consumers and families must be involved and empowered in the treatment process, and supportive crisis plans are needed to facilitate recovery and acceptance of treatment 1. The American Psychiatric Association recommends that patients with schizophrenia have a documented, comprehensive, and person-centered treatment plan that includes evidence-based nonpharmacological and pharmacological treatments 1. The guideline also recommends that patients with schizophrenia be treated with an antipsychotic medication and monitored for effectiveness and side effects 1. In-patient care may be required if there is a significant risk of self-harm or aggression, if the level of support in the community is insufficient, or if the degree of crisis is too great for the family to manage, as stated in the international clinical practice guidelines for early psychosis 1. Examples of appropriate initial target doses for most patients are risperidone 2 mg/day or olanzapine 7.5–10.0 mg/day, as suggested by the guidelines 1. Extrapyramidal side-effects from antipsychotic treatment should be avoided in order to encourage future adherence to medication, and clinical guidelines recommend that treatment should commence prior to the development of a crisis, such as self-harm, violence or aggression, and may be an appropriate alternative to in-patient admission 1. The goal of treatment is to reduce the mortality, morbidity, and significant psychosocial and health consequences of psychosis, and to enhance the treatment of schizophrenia for affected individuals, as stated in the American Psychiatric Association practice guideline for the treatment of patients with schizophrenia 1.

From the Research

Hospitalization Criteria for Psychosis

To determine if a patient with psychosis needs to be hospitalized, several factors must be considered, including:

• Severity of symptoms: Patients experiencing severe psychotic episodes, such as hallucinations, delusions, or disorganized thinking, may require hospitalization 2.
• Risk of harm to self or others: Patients with suicidal or homicidal thoughts, or those who have exhibited self-harming behaviors, may need to be hospitalized to ensure their safety and the safety of others 3, 4, 5, 6.
• Ability to function: Patients who are unable to care for themselves, manage their daily lives, or maintain social relationships due to their psychotic symptoms may require hospitalization 2.
• Presence of co-occurring conditions: Patients with co-occurring medical or neurologic conditions, such as delirium or dementia, may require hospitalization to address these underlying conditions 2.
• Response to treatment: Patients who have not responded to outpatient treatment or have experienced a significant worsening of symptoms may require hospitalization to receive more intensive treatment 2.

Assessing Suicidal Ideation

When assessing a patient with psychosis for hospitalization, it is essential to evaluate their risk of suicidal ideation, which is a significant concern in patients with psychotic disorders 3, 4, 5, 6. Factors associated with suicidal ideation in psychosis include:

• Depressed mood
• Anxiety
• Low self-esteem
• Negative illness perceptions
• Negative evaluative beliefs about the self and others
• Daily alcohol consumption
• Presence of hallucinations and delusions, particularly those that are distressing or commanding 4, 5, 6.

Treatment and Intervention

Hospitalization may be necessary to provide patients with psychosis a safe and supportive environment to receive treatment and stabilize their symptoms 2. Treatment may include:

• Medications to manage psychotic symptoms, such as antipsychotics
• Therapies, such as cognitive-behavioral therapy, to address underlying issues and improve coping skills
• Support and education for patients and their families to help them manage the condition and reduce the risk of suicidal ideation 3, 4, 5, 6.