Optimize the benefits and minimize the adverse effects of antipsychotics in patients with acute schizophrenia
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Optimize the benefits and minimize the adverse effects of antipsychotics in patients with acute schizophrenia Acute psychosis in patients with schizophrenia is a medical emergency that requires a rapid treatment response. Antipsychotic drugs are the cornerstone of individualized treatment and are aimed at reducing agitation, controlling psychotic symptoms and preventing psychosis relapse and recurrence.
Requires immediate treatment Schizophrenia is a common condition (lifetime prevalence ≈ 1%)[1] and is a leading cause of disability.[2] Although schizophrenia typically has an insidious onset with subtle symptoms such as amotivation, social withdrawal, depression and cognitive dysfunction, the patient will often first present with psychotic symptoms, including disordered thinking, delusions and hallucinations.[3] As schizophrenia commonly runs a chronic or recurrent course, acute or subacute psychotic states occur frequently.[3] During a florid psychotic state, the patient may show extreme motor restlessness, irritability and lack of insight,[3] and is at high risk of harming self[4] or others.[5]
Control symptoms and prevent harm to self and others The initial objectives of treatment are generally to reduce agitation and psychotic symptoms and to ensure the safety of the patient and others.[6] Individualized management will depend on patient characteristics, including the level of agitation, level of suicide risk, co-morbid drug intoxication or withdrawal, and whether it is a first or subsequent illness episode.[6] Elderly patients also require particular care with respect to differential diagnosis and drug management.[6] Patients with antecedents of suicide (depression, social isolation, suicidal ideation, past suicide attempts) require hospitalization with round-the-clock observation and monitoring of suicide risk.[6] Similarly, hospitalization is usually necessary for patients who are highly agitated or with co-morbid drug dependence.[6] However, some well supported patients whose condition is well known to the treating clinicians may be managed as outpatients, assuming home-care crisis services are available.[7]
Assess carefully During the first days of hospitalization, careful assessment is required to confirm the diagnosis of Drugs Ther Perspect 2009; Vol. 25, No. 10
schizophrenia, assess illness severity and suicide risk, and to diagnose co-morbid psychiatric and medical conditions.[6] Assessment should include a medical history, ECG and blood tests.[6] In elderly patients, it is essential that the clinician identify co-existing medical conditions and distinguish between schizophrenia and dementia with psychosis; antipsychotic drugs are contraindicated in latter condition, because they are associated with an increase in mortality and cerebrovascular disease.[6] In patients judged to be at high risk for suicide, the contribution of hallucinations to suicidal ideation should be assessed and monitored, as patients remain at high risk while hallucinations urging suicide persist.[8] Some consideration can als
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