How To Treat Psychotic Patients

How To Treat Psychotic Patients – Most psychosis occurs in adolescence or young adulthood, but some develop later in life. Here’s how to recognize and treat them.

Psychosis usually appears early in life, but may occur for the first time in older patients. These cases present unique challenges. Morbidity and mortality rates for mental disorders in late life are significantly higher than for mental disorders in young adults.

How To Treat Psychotic Patients

But once doctors identify the root of the problem, they have many effective treatment options.

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When defining late-onset psychosis, a distinction must be made between primary psychosis and secondary psychosis.

The term primary psychosis describes conditions in which psychotic symptoms are the main clinical manifestation of the illness. Primary psychiatric disorders include illnesses along the schizophrenia spectrum, major depressive disorder (MDD), and bipolar disorder with psychotic features.

The term secondary psychosis refers to psychosis that is a secondary or co-occurring symptom rather than the main clinical feature of the disorder. Examples of secondary psychosis: delirium, neurocognitive disorder, psychosis due to a drug or prescription drug overdose, or psychosis due to medical or neurological disorders.

Acute or subacute symptoms may indicate delirium or substance- or drug-induced psychosis. The presence of symptoms may indicate a primary psychiatric disorder, such as schizophrenia spectrum disorders.

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Signs that indicate secondary psychosis include abnormal age of onset, visual hallucinations that appear independent of auditory hallucinations, psychotic symptoms in a person without a prior or family history of psychosis, and abnormal physical examination findings. , or evidence of abuse of prescription drugs or illegal substances.

For secondary psychiatric disorders, initial treatment includes addressing potential causes, including discontinuation of harmful medications and drug use, and treatment of underlying medical or neurological causes.

Antipsychotic drugs should be prescribed with caution in the elderly, because their long-term use can cause significant adverse effects.

Before initiating antipsychotic drug therapy, clinicians should perform a risk-benefit analysis based on the individual’s physical status and comorbidities.

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Starting with a low dose (1/4 to half of the initial adult dose) and gradually titrating to the optimal dose may reduce the incidence of side effects.

Evidence suggests that risperidone and olanzapine may be useful in the treatment of older adults with schizophrenia.

One randomized controlled trial with a dose of ​​100 mg/day of amisulpride (not available in the US in patients diagnosed with late-onset schizophrenia) showed a significant improvement in the Brief Psychiatric Rating Scale compared with placebo .

Expert consensus guidelines recommend risperidone 1.25 mg to 3.5 mg daily followed by quetiapine 100 mg to 300 mg daily, olanzapine 7.5 to 15 mg daily, or aripiprazole in older adults with schizophrenia. 15 mg to 30 mg per day.

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Clozapine use is less common among older people with psychiatric disorders, which may be due to significant adverse effects.

Among older adults with MDD with psychotic symptoms, the combination of olanzapine and sertraline had a higher remission rate during treatment than olanzapine or placebo, and the combination was well tolerated.

In a systematic review of meta-analyses evaluating the use of antipsychotics among people with dementia, researchers found that antipsychotics are modestly effective in treating psychosis, aggression, and agitation.

The use of these drugs is often limited by their AE profile. For severe symptoms that do not respond adequately to non-pharmacological treatment strategies, antipsychotic medications are recommended, the researchers noted.

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A meta-analysis that evaluated the prevention and treatment of delirium among surgical and hospital patients found that antipsychotics have limited efficacy in the treatment of delirium.

There is considerable controversy regarding the use of antipsychotics in older adults with severe psychosis due to dementia.

The FDA has a boxed warning indicating that antipsychotic use is associated with an increased risk of death among older adults with dementia.

In addition, the use of antipsychotic medications in this patient population increases the risk of cerebrovascular adverse events, metabolic adverse events, and pneumonia compared to age-matched controls who were not prescribed these medications.

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In the elderly, antipsychotics should be discontinued as soon as clinically possible to avoid serious adverse effects.

Attempting to discontinue antipsychotics in the elderly is prudent only if 1 or more of the following 3 conditions are met: (1) the patient has not responded adequately to the medications; (2) the medication caused intolerable side effects; or (3) the individual demonstrated sustained clinical remission. If the drugs cannot be discontinued because of psychotic symptoms, an attempt should be made to reduce the drug dose to the lowest effective dose.

Bilateral electroconvulsive therapy has been shown to be a safe and effective treatment in elderly patients with schizophrenia, especially those with catatonia, aggression or suicidality, or with acute symptoms, in combination with antipsychotic medications. .

Available data demonstrate the effectiveness of cognitive-behavioral social skills training (CBSST), functional adaptive skills training (FAST), supported employment, social skills training, and health prevention programs for older adults with dementia.

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In addition, older adults with schizophrenia have improved work outcomes and improved quality of life compared to traditional vocational rehabilitation programs.

Most cases of late-life psychosis are caused by underlying medical or neurological conditions, or by the effects of drugs or illegal drugs. Primary and secondary causes can be established by a careful history, a complete mental status examination, a focused physical examination, appropriate laboratory data or imaging studies and a formal neuropsychological evaluation in difficult-to-diagnose cases.

The use of antipsychotics in the elderly is associated with significant risks, including an increased risk of death in those with dementia, because of the adverse effect profile of these drugs. In the elderly, antipsychotics are recommended in the lowest effective dose and for the shortest duration.

Early detection and prompt treatment or treatment of secondary causes of psychosis will reduce unnecessary suffering in vulnerable older adults. Psychotherapy has been shown to be effective in the treatment of primary psychiatric disorders in the elderly. Future studies should focus on the risk factors, neurobiology and treatment of late-onset dementia so we can better understand and treat these diverse disorders.

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Is Professor and Chair of the Department of Psychiatry and Behavioral Sciences at the Cleveland Clinic Akron, and Chief of Geriatric Psychiatry at the Cleveland Clinic Department of Psychiatry and Psychiatry.

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