Psychosis Management

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Core management
  • If delirium, dementia, depression, alcohol/drug related – see other sections
  • Psychoeducate patient and guardians
  • Stop any drugs likely to make it worse
  • Start antipsychotic and titrate up to an effective dose
  • Manage any side-effects

Red Flags

Refer or admit if necessary:

  • If there is a high risk of self-neglect, vulnerability, harm to others or suicide.
  • If insight is lacking and no guardian can ensure compliance with medication.
  • If the person refuses to go to hospital you may need to detain them using the Mental Health Act. (see Part 3 of this guide).

Investigations

Look for physical cause for the symptoms:

  • Try to rule out delirium, drug and alcohol use/withdrawal etc.
  • Full physical exam
  • FBC, VDRL, MRDT, HIV
  • Urine drug screen if available

Psychosocial

  • Supportive counselling about the illness
  • Psychoeducation of guardians – photocopy information leaflet on psychosis
  • Promote functioning in daily activities
  • Reduce stress and strengthen social supports

Medication

Commence antipsychotic drug (the following are adult doses, use lower doses in over 65s – see chapter in Part 5).

Start at lower dose range if first episode.

Discuss importance of compliance - note it takes 1-2 weeks for medications to work. Increase gradually to usual treatment dose for 2 weeks before switching, unless side-effects intolerable.

  • Start Chlorpromazine 100 – 300mg nocte

Or

  • Haloperidol 2.5 – 5mg nocte
  • If no improvement after 2 weeks at effective dose or experiencing lots of side-effects (see box) switch to Risperidone 1-2mg nocte

If psychosis could be due to a manic episode, stop any anti-depressant drugs as they will make it worse.

In drug-induced psychosis, if the person stops using the drug, the symptoms may resolve. A short course of oral Diazepam 10mg bd for one week may help withdrawal symptoms.

In cases of chronic psychosis and where compliance to oral meds is poor (despite counselling and attempts to manage side-effects) consider a long-acting depot such as:

  • Fluphenazine 12.5mg im into a large muscle as a test dose followed by Fluphenazine 25 – 50mg im every 4 weeks. Dose can be increased by 12.5 – 25mg after at least 3 months.

Side Effects

Chlorpromazine: sedation, postural hypotension (dizziness on standing), constipation, photosensitivity (rash in sunlight). Haloperidol: extra-pyramidal side effects (EPSE) (tremor, rigidity, slowed movements), salivation.

Acute dystonia (rapid onset of severe muscle stiffness e.g. neck turning to one side, eyes rolling upwards) is a very distressing EPSE. Stop antipsychotic, give Trihexyphenidyl (“Artane” / “Benzhexol”) 5mg orally, IM or IV max tds. Refer urgently.

If chronic EPSE, reduce dose of antipsychotic and/or add Trihexyphenidyl (“Artane” / “Benzhexol”) 5mg orally daily. Refer for review.

Referral

  • Persisting/worsening symptoms despite 6-8 weeks of antipsychotic medication at effective dose.
  • If side-effects are not manageable (see above)

Follow-Up

  • Review every 1-2 weeks initially and then every 1 month once more stable.
  • Screen for ongoing symptoms and monitor for medication side-effects at each review.
  • Continue medication for at least one year from complete symptom resolution if this is a first episode, or several years if multiple episodes.
  • If psychosis is secondary to drug use, consider withdrawing medication six months after complete symptom resolution.