Psychosis medication

Delirium. Closely related to the previous disorders is delirium, which includes both psychosis and a fluctuating level of consciousness. The fluctuating sensorium is the key to distinguishing delirium from other causes of psychosis. Medical illnesses or drugs cause delirium it is a medical emergency that requires prompt medical treatment. 

Cluster A patients rarely call attention to themselves and often suffer in isolation for much of their lives. They may be brought to treatment by a family member, or if they are employed, there may be a problem in the workplace that precipitates referral. By their nature, those with Cluster A personality disorders are difficult to engage in any modality of therapy, including medications. If the person has deteriorated in mental health to the point of developing a psychosis, medication may be considered for the specific target symptoms. Also, therapists should carefully... 

Before starting therapy for the hospitalized patient, the nurse obtains a complete psychiatric and medical histoiy. In the case of psychosis, patients often are unable to give a reliable histoiy of their illness. When a psychosis is present, the nurse obtains the psychiatric histoiy from a family member or friend. During the time the histoiy is taken, the nurse observes the patient... 

Phencyclidine (PCP) abuse remains a serious public health problem in large urban areas of the United States, with recent trends suggesting increased use after a period of decline (Crider, this volume). Most clinical and research attention has focused on the psychiatric and medical manifestations of acute or subacute PCP intoxication, especially the organic mental disorders (toxic delirium, psychosis, or depression) that PCP can induce (McCarron et al. 1981 McCarron, this volume Sioris and Krenzelok 1978). 

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. 

To date, clozapine remains the only drug with proven and superior efficacy in treatment-resistant patients, and it is currently the only drug approved for the treatment-resistant schizophrenic. Studies have shown a response of approximately 30% to 50% in these well-defined treatment-resistant patients. Clinical trials have consistently found clozapine to be superior to traditional antipsychotics for treatment-refractory patients, and it is efficacious even after nonresponse to other SGAs and in partially responsive patients. It is often rapidly effective even in those who have had a poor response to other medication for years. Recent studies have demonstrated that it has a beneficial effect for aggression and suicidality, which led to the Food and Drug Administration (FDA) approval for the treatment of suicidal behavior in people with psychosis.41... 

Assess the patient s symptoms, review patient and family history, and obtain initial medical evaluation to rule out other causes of psychosis. 

Optimize the dose of mood stabilizing medication(s) before adding on lithium, lamotrigine, or antidepressant (e.g., bupropion or an SSRI) if psychotic features are present, add on an antipsychotic ECT used for severe or treatment-resistant depressive episodes or for psychosis or catatonia... 

The positive symptoms are the most responsive to antipsychotic medications, such as chlorpromazine or halo-peridol. Initially, these drugs were thought to be specific for schizophrenia. However, psychosis is not unique to schizophrenia, and frequently occurs in bipolar disorder and in severe major depressive disorder in which paranoid delusions and auditory hallucinations are not uncommon (see Ch. 55). Furthermore, in spite of early hopes based on the efficacy of antipsychotic drugs in treating the positive symptoms, few patients are restored to their previous level of function with the typical antipsychotic medications [2]. 

There is less risk of developing motor complications from monotherapy with dopamine agonists than from L-dopa. Because younger patients are more likely to develop motor fluctuations, dopamine agonists are preferred in this population. Older patients are more likely to experience psychosis from dopamine agonists therefore, carbidopa/L-dopa may be the best initial medication in elderly patients, particularly if cognitive problems or dementia is present. 

Consider atypical antipsychotic medication if disruptive hallucinosis or psychosis persists. 

Antipsychotic medications have traditionally been used to treat disruptive behaviors and psychosis in AD patients. 

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. 

The prevalence rates of schizophrenia are lower in old age than in younger age groups (Copeland et al. 1998). The incidence of Alzheimer s disease with psychosis is much more frequent than the incidence of schizophrenia in old age (Jeste and Finkel 2000). For the frail Alzheimer s patients, medications may induce or aggravate the symptoms. 

When we talk about what a psychiatric medication does, we are invariably discussing its effect on neurotransmission between nerve cells across the synapse. Psychiatric medications act by modulating chemical neurotransmission in the synapse. However, as you probably know, it often takes several days or weeks for depression or psychosis to respond to treatment. Clearly, psychiatric medications work. Why, however, is there often a delay before they begin to do so ... 

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. 

The mental status examination remains an essential part of the evaluation. Often patients with schizophrenia will appear nnkempt or otherwise oddly dressed. Sometimes they will be friendly and affable, but when they are paranoid, they can be angry and hostile. Patients may have odd stereotypical movements that can become extreme in catatonic states. The patient with schizophrenia is usually quite alert and well oriented to his/her surroundings. This observation helps to distinguish the psychosis of schizophrenia from that of a delirium due to a medical illness or substance use. 

Psychotic Disorder Due to Generai Medical Condition. Certain medical illnesses occasionally present with symptoms of paranoid delnsions or hallucinations that resemble schizophrenia (Table 4.4). When these illnesses are snccessfully treated, fnll resolntion of the psychotic symptoms invariably occnrs. All patients presenting with new-onset psychosis shonld nndergo a thorongh medical evaluation including a physical exam, family and personal medical history, and laboratory stndies inclnding electrolytes, thyroid function tests, syphilis screen, vitamin B12 and folate levels, and a CT or MRI brain scan. A lumbar puncture (spinal tap) and electroencephalogram are sometimes also warranted. 

The key to distinguishing schizophrenia from a psychotic mood disorder is to obtain a history of the patient prior to the acute episode of psychosis. This includes both the past history from medical and psychiatric records and collateral history... 

Loxapine (Loxitane). Loxapine is a medium potency antipsychotic, and it has several interesting features. First, it is chemically very similar to clozapine, the first of the atypical antipsychotics. In the test tube, loxapine actually behaves more like an atypical antipsychotic (more on that later), but when patients are treated with it, loxapine acts more like a traditional typical antipsychotic. A second point of interest is that loxapine is actually the major active metabolite of the antidepressant amoxa-pine (Ascendin). As a result, one can use a single medication (amoxapine) to treat both depression and psychosis. In practice, however, the use of what is essentially a fixed dose combination medication should be avoided. Using amoxapine does not allow separate adjustment of the antipsychotic and antidepressant, and most importantly, amoxapine is the only antidepressant associated with the risk of TD. 

Atypicai Antipsychotics. In the 1980s and early 1990s, the SSRIs began a revolution in the treatment of depression. Tried-and-true but side effect laden tricyclic antidepressants fell into disfavor as newer and safer medications became available. A similar revolution is taking place in the treatment of psychosis. A new generation of antipsychotics that have fewer of the more disturbing side effects and may well be more effective are now available. 

In the era of modern psychiatry, the treatment of schizophrenia has undergone two revolutions. The first revolution began in the 1950s with the debut of the typical antipsychotics, the first proven effective treatments for psychosis. These medications enabled patients who in years past would have been relegated to long-term hospitalization to return to the community. 

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