Psychosis management

Challoner, J. Invisible psychosis a survey of patients with psychosis managed by GPs without input from secondary care. 2006. 

CMHT - psychosis management - initial (Ch.23) and longer-term (Ch.24)... 

Ward - most psychosis management decisions are made in team ward rounds, but you ll often be alone if and when neuroleptic malignant syndrome strikes (Ch.67)... 

Luisada, P.V., and Brown, B.I. Clinical management of the phencyclidine psychosis. Clin Toxicol 9 531-545, 1976. 

The treatment goals for acute intoxication of ethanol, cocaine/amphetamines, and opioids include (1) management of psychological manifestations of intoxication, such as aggression, hostility, or psychosis, and (2) management of medical manifestations of intoxication such as respiratory depression, hyperthermia, hypertension, cardiac arrhythmias, or stroke. 

Common side effects of dopamine agonists are nausea, confusion, hallucinations, lightheadedness, lower-extremity edema, postural hypotension, sedation, and vivid dreams. Less common are compulsive behaviors, psychosis, and sleep attacks. Hallucinations and delusions can be managed using a stepwise approach (Table 55-4). When added to L-dopa, dopamine agonists may worsen dyskinesias. 

Stepwise Approach to Management of Drug-Induced Hallucinosis and Psychosis in Parkinson s Disease... 

Selection of an antipsychotic should be based on (1) the need to avoid certain side effects, (2) concurrent medical or psychiatric disorders, and (3) patient or family history of response. Fig. 71-1 is an algorithm for management of first episode psychosis. 

Three tasks comprise the goals of the acute phase of treatment. First, an appropriate mood stabilizer must be chosen and safely initiated. Second, agitation and psychosis, if present, must be managed while waiting for the mood stabilizer to take effect. Third, the patient s sleep must be optimized. 

Management of Agitation and Psychosis. Like antidepressants, mood stabilizers do not work immediately. It often takes a week or longer for a mood stabilizer to reach a therapeutic level and exert its beneficial treatment effects. Meanwhile, one may have a labile, impulsive, and agitated patient on one s hands. Clearly, rapidly acting tranquilizing medications are needed at this juncture to calm an agitated patient. 

Atypical antipsychotics may be helpful in managing the delusions and agitated behavior that can accompany dementia. These medications, include risperidone (Risperdal), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), and olanzapine (Zyprexa). All antipsychotics, typical and atypical, appear to increase the risk of death in patients with dementia and psychosis. This appears as a warning in the package inserts of the newer drugs. A prudent approach is to discuss this risk with the caregiver, use the lowest effective dose, and monitor for effectiveness. 

Ryan JM. Newer generation antipsychotics for the management of psychosis in older patients with dementia. J Clin Psychiatry 2003 64(11) 1388-1390. 

Disulfiram is used as an adjunct in the management of alcohol dependence. It is contraindicated in patients with a history of cerebrovascular accident, cardiac failure, coronary artery disease, hypertension and psychosis. Side-effects that may be present include initial drowsiness and fatigue, nausea, vomiting, halitosis, reduced libido, psychotic reactions, allergic dermatitis, peripheral neuritis and hepatic cell damage. 

Fenthion has also exhibited delayed neurotoxicity in which the initial cholinergic crisis was delayed 5 days and recurred 24 days after ingestion. Psychosis was a persistent manifestation. Because of the high lipid solubility of fenthion, toxin analysis of repeated fat biopsies was an essential component of patient management. ... 

Violent acts are a part of the drug abuse scene. Such acts may result from psychosis and excitable states produced by substances such as amphetamines and similar, from frustrated attempts to obtain substances, by merciless substance vendors - the pushers (who may themselves be abusers), and from the criminal sub-culture which can attract and prey on those who hopelessly substance dependant. One should take care in managing all situations with substance abusers to avoid personal risk, which must also include the risk of infection with HIV and hepatitis. 

Qf-adrenergic and Hi histamine receptors. It is used for the treatment of psychosis but also for sedation and for the management of manic states. Thiothixene is used for the same indications but is less sedative than chlorprothixene. 

Jensen S, Plaetke R, Holik J, et al Linkage analysis of the Dj dopamine receptor gene and manic depression in six families. Hum Hered 42 269-275, 1992 Jeste DV, Eastham JH, Lacro JP, et al Management of late-life psychosis. J Clin Psychiatry 57 [suppl 3) 39-45, 1996... 

Overdose of stimulants may lead to signs and symptoms of sympathetic overstimulation, including tremors, hypertension, fever, tachycardia, hyperreflexia, confusion, agitation, and frank psychosis or delirium. Management typically involves supportive measures to treat fever, severe hypertension, seizures, agitation, and other signs and symptoms. 

The final area specifically considered here which poses major problems in diagnosis and management is that of drug-induced psychosis, and a helpful editorial in the British Journal of Psychiatry was critical of the understanding of this concept (Poole Brabbins 1996). The authors point out that although drug-induced psychosis is routinely included in the... 

It is well established that monotherapy with various antidepressants or mood stabilizers is relatively ineffective (i.e., they are necessary but not sufficient) for treating mood disorders with associated psychosis. Thus, psychotically depressed patients are best managed with a combination of antipsychotic-antidepressant or with electroconvulsive therapy. Although antipsychotics have a more rapid onset of action than lithium in an acute manic episode, we are unaware of clinical trials that examine the differential effect of antipsychotics or lithium for nonpsychotic versus psychotic mania. This topic is discussed further in... 

Management of Acute Psychosis Efficacy for Acute Treatment... 

Before the discovery of the neuroleptics, episodes of psychotic excitement were usually managed with i.v. amobarbital in doses sufficient to heavily sedate or actually put patients to sleep. Upon awakening, they were often much less excited. The role that sleep deprivation plays in the onset of psychotic symptoms may be a partial explanation for this beneficial effect. Although sedatives have no specific effect on the underlying psychosis, they can calm psychotic excitement. Because the extreme excitement, rage, and explosivity often associated with a psychotic exacerbation are amenable to intervention with sedatives, this raises the possibility that these symptoms may have a different underlying mechanism than that subserving the psychosis itself. 

Antipsychotics have a broad-spectrum effect, improving psychosis in schizophrenia, schizophreniform disease, mania, and organic psychosis but response to lithium suggests an affective core. Whereas almost all schizophreniform patients are presently treated with antipsychotics, it is possible that lithium may be more specific and safer in the management of at least some of these patients. 

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