Management of Patients Presenting with Acute Psychotic Episodes of Schizophrenia

Abstract

The initial management of patients with schizophrenia presenting to psychiatric emergency departments with an acute psychotic episode requires rapid decisions to be made by physicians concerning the treatment of individuals who are likely to be relatively uncooperative, agitated and lacking insight. The treatment decision must be adapted to the individual characteristics and needs of each patient. This article reviews the issues from the perspective of the initial management of acute psychosis as it is currently practised in Europe, and discusses the pragmatic implications for initial treatment decisions and the elaboration of a long-term treatment plan. Initially, administration of antipsychotics to control psychotic symptoms and benzodiazepines to control agitation represents the cornerstone of treatment. Oral medication is preferable to injectable forms wherever possible, and atypical antipsychotics are to be preferred over conventional agents because of their lower risk of extrapyramidal adverse effects, which are a major determinant of poor adherence to treatment. Whatever antipsychotic is chosen by the physician during the initial period, it is likely that it will need to be continued for many years, and it is thus important to take into account the long-term safety profile of the drug chosen, particularly in relation to extrapyramidal adverse effects, metabolic complications and quality of life. Building a therapeutic alliance with the patient and his/her family or carers is an important element that should be included in the initial management of psychosis. The long-term goal should be to minimize the risk of psychotic relapse through adequate treatment adherence.

Acute and Transient Psychosis: An Overview

“…However, there are few studies with which to make meaningful comparisons. A similar trend was previously reported from earlier studies (Thomas et al 2009) on mortality of reactive psychoses. It was reported that there was a significantly raised mortality risk in reactive psychosis, and suicide was the largest cause of premature death.…”

“…Similarly, a study by Perris (1974) found that patients with cycloid psychosis on continuous lithium treatment experienced fewer repeat episodes. General treatment recommendations for patients presenting with their first episode of psychosis, including psychotic disorders with acute onset, include a comprehensive assessment to evaluate comorbidities and rule out organic and substance-induced causes (Thomas et al 2009). A typical antipsychotics, often at low initial doses, are recommended as the first line of medication treatment, with continuation of treatment for 1 year (Jabs et al 2002).…”

“…A typical antipsychotics, often at low initial doses, are recommended as the first line of medication treatment, with continuation of treatment for 1 year (Jabs et al 2002). It is also recommended that there should be coordination between treating team, the patient's family and/or friends to help ensure treatment adherence and to educate them about the disorder (Thomas et al 2009). There is also need for international treatment guidelines for acute episode of ATPD.…”

Trace Amines and Their Receptors

“…Second-generation (atypical) antipsychotics are currently the mainstay of therapy for both disorders and include compounds such as clozapine, olanzapine, quetiapine, risperidone, and aripiprazole. These second-generation compounds are associated with less severe extrapyramidal symptoms but are associated with a metabolic syndrome (dyslipidemia, insulin resistance, pronounced weight gain, and elevations in blood pressure), which can unfavorably alter the benefit-risk ratio (Gründer et al, 2009;Kim et al, 2009;Meyer and Stahl, 2009;Thomas et al, 2009). The metabolic syndrome and obesity are estimated to occur in 33% of patients with schizophrenia and bipolar disorders.…”

Patient perspectives on antipsychotic treatments and their association with clinical outcomes

“…12,13 Moreover, some research suggests that patients receiving atypical antipsychotics have more favorable subjective responses to their current medication than those receiving conventional medications. [14][15][16] However, other studies report no difference or suggest patient characteristics may be responsible for differences in adherence rather than type of medication.…”