Managing first episode of psychosis • • • • Should ideally be managed by a psychiatrist Evaluate if admission to hospital is needed: - the risk of harm the patient poses to themselves or others - the patient’s level of insight and disorganised thinking and their competency to make decisions - availability of community mental health resources and family or other social support. Antipsychotics are to be continued after an acute episode to facilitate recovery and prevent relapse and suicide. If possible delay starting them on an antipsychotic for 24 to 48 hours to facilitate assessment and diagnosis. Managing Agitation • • • • Agitation is common and settles within a few days Only provide treatment if safe and appropriate to do so. If diazepam or lorazepam cannot be used, use a suitable dose of the patient’s antipsychotic as needed - Do not exceed the maximum daily dose - If long acting injectable us used -> approximate the equivalent oral dosage - Some data suggests that as needed/prn may make additation and risk of adverse effects worse Consult a psychaitist to consider zuclopenthixol if: - Inadequate response to other therapy - Disturbed behaviour for an extended period of time ➔ 24 to 48 hours - History of good response to this medication - History of requiring repeated administration of intramuscular durgs for acute behavioural disturbances Choosing an antipsychotic • • • • • • For first time psychosis -> after observing the patient for 24 to 48 hours Must balance efficacy, short and long term tolerability. If drugs efficacy is similar, determine based on adverse effects and overall patient health (including physical) First line antipsychotics for first time psychosis - Amisulpride, aripiprazole, olanzapine, quetiapine, risperidone and ziprasidone ➔ Minimal difference in efficacy between them ➔ For those under 18, ziprasidone is not effective Second line antipsychotics for first time psychosis - asenapine, brexpiprazole, lurasidone and paliperidone Because of cost or availability, the older antipsychotics chlorpromazine, haloperidol, periciazine or zuclopenthixol are used to treat psychosis. - Effective, but more likely to cause extrapyramidal side effects, treatment discontinuation, and lower quality of life Monitoring and titrating antipsychotic theraoy for a ifrst episode of psychoiss • • • • • Assessmenr of treatment response and monitoring for side effects If day time sedation is an issue -> give dose at night Positive symptoms should imporve within a week The frequency of dose increase depends on the patient - Some patients require a slower dose increase ➔ E.g. younger and older patients If there is still minimal response after four weeks of treatment at maximum dose or no response after 2 weeks and alternative reasons for treatment failure have been excluded, switch to an oral antipsychotic with different dopaminergic receptor occupany profile. Durnation • • • Minimum durnation depends on durnation of symptoms and how quickly the patient responds to treatment If symptoms last for more than 6 months - At least 2 years after symptom reduction ➔ A longer durnation is often needed If symptoms resolve in less than 6 months and patient does not have a delusion disorder - For at least a year