BMJ review focuses on the management of acute psychotic episodes

A recent BMJ review focuses on the management of a common psychiatric emergency - the acute psychotic episode.Acute psychosis is one of the most common psychiatric emergencies, and the first five years following of psychotic illness is considered 'the critical' period as this is when patients are at highest risk of suicide. For this reason, appropriate intervention is critical during this time and can also be the most fruitful. In his current review, Peter Byrne discusses the current management of the acute psychotic episode.Causes of psychosis range from all forms of dementia and neurological disorders such as epilepsy, head injury, infarction, infection and tumours, to most causes of delirium. "Comorbidities are common and increase with age - monitoring for hidden physical and other mental disorders is essential," he notes.Diagnosis is based on clinical findings. While investigations are required to rule out organic psychosis, no laboratory tests are currently available to confirm the diagnosis of psychosis. Byrne provides a list of laboratory tests listing their implications and what they can effectively rule out.Byrne notes that there are three core areas when assessing a patient with suspected psychosis. These comprise history, mental state examination and collateral history. Many aspects of a patient's history determine diagnosis and management including neurological and endocrine symptoms, past psychiatric symptoms, medication history, a family history of mental illness, alcohol and substance misuse, and adverse drug reactions. "Taking collateral details after clinical assessment is an opportunity to test the working diagnosis," he notes.He recommends that non-organic psychoses are best treated by mental health services in the least restrictive setting, and that patients with acute psychosis should be managed with pharmacotherapy. "Treatment achieves complete remission, without relapse, in 25% of patients," he asserted. In his review he recommends that one antipsychotic drug be given at the lowest effective dose, and provides a list of drugs that have been shown to be effective for acute psychosis by way of Cochrane reviews. In addition, he lists a range of psychosocial interventions for psychosis and detailed what systematic review evidence is available to support these interventions."After recovery (full or partial), a single antipsychotic drug is given prophylactically, usually at a lower dose than that needed for treating acute illness. Treatment of a first episode is recommended for one year, followed by gradual cessation in asymptomatic patients at low risk. Risk of relapse is indicated by residual disability, family history of psychosis, or current substance misuse. Patients at risk and those with multiple psychotic episodes require longer prophylaxis," he summarised. He pointed out that people with a history of violence need more intensive case management, which may include prolonged medication under supervision.Byrne concluded that while a perfect antipsychotic drug that lacks disabling side effects is still eagerly awaited, in the meantime coordinated interventions can maximise patient functioning and prevent relapse.Reference...