Approach
There are few research data on brief psychotic disorder (BPD) to guide evidence-based treatment recommendations and clinical management.[8][31] However, evidence-based treatments for other psychotic disorders are applicable for the short-term resolution of BPD symptoms.[32]
Management should include both psychosocial interventions and pharmacological treatments. Referral to a psychiatrist or psychiatric team is appropriate for further follow-up.[33] Long-term monitoring is important for the following reasons:
To assess for relapse
To assess for circumstances that may precipitate a referral to a mental health professional
To address involvement in collateral family supports to ensure adherence to treatment
General approach
Patients can present with BPD with marked stressors, without marked stressors, or postnatal. The general approach to management combines antipsychotic medicine and psychotherapy.[22][33] Psychotherapy is focused on helping the person to cope with the stressor or with postnatal issues. In all patient groups, the duration of medicine treatment will depend on the duration and severity of the symptoms, risk of harm to self or others, whether the patient or their support are likely to be able to respond to early signs of relapse, and whether there are concerns about a possible mood disorder.[22]
Patients' current BMI and cardiac risk factors should be considered before prescribing certain antipsychotics that can cause weight gain and other metabolic adverse effects.[33]
Patients who pose a threat to themselves or others (e.g., who are suicidal, homicidal, aggressive, or combative) may require a brief hospitalisation for evaluation and safety.
Able to accept or tolerate oral treatment and/or presenting at clinic
At presentation it is not known what the diagnosis is, and the psychotic symptoms are treated with antipsychotic medicines. In BPD all symptoms resolve and the patient returns to normal functioning. In cases of complete symptom resolution, an attempt to taper and discontinue the antipsychotic medicine should be considered, and treatment is generally not needed past 1 month. Psychosocial treatments (psychotherapy and family support) should be offered to all patients presenting with BPD.[33][34]
First-line oral treatment is with a second-generation antipsychotic drug. These include olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole, or paliperidone.
Oral first-generation antipsychotic drugs are second-line treatment. Options include haloperidol, chlorpromazine, perphenazine, fluphenazine, trifluoperazine, and loxapine. Extra-pyramidal adverse effects are common with first-generation antipsychotics. Prophylactic treatment (e.g., benzatropine) can be given to reduce adverse effects.
Lorazepam can be given for its anxiolytic effect when there is the need for rapid sedation of violent or agitated individuals.
Acutely agitated, presenting to accident and emergency department, and refusing or unable to tolerate oral medicine
Patients presenting with floridly psychotic symptoms and agitation are generally seen in the accident and emergency department setting, and often require immediate antipsychotic treatment. Patients who pose a threat to themselves or others (e.g., suicidal, homicidal, aggressive, or combative) may require a brief hospitalisation for evaluation and safety. Oral medicines should be considered and offered as first-line treatment; however, intramuscular treatment is often needed. Intramuscular antipsychotic treatment should be replaced with oral antipsychotic medicine within 3 days. Psychosocial treatments (psychotherapy and family support) should be offered to all patients presenting with BPD.[33][34]
Second-generation antipsychotic drugs are considered first-line treatment due to their lower risk of extra-pyramidal adverse effects, which occur at high rates in people who have never been treated with antipsychotic medicines before. Olanzapine, aripiprazole, and ziprasidone are available in intramuscular formulations and can be substituted for oral medicine once the patient is stabilised. [
]
An intramuscular first-generation antipsychotic drug (haloperidol) is second-line treatment. Treatment with haloperidol should only be given at the lowest possible dose, with extra-pyramidal adverse effect prophylactic treatment (e.g., benzatropine or diphenhydramine) to reduce adverse effects.[35]
Lorazepam can be given adjunctively for its anxiolytic effect when there is the need for rapid sedation of violent or agitated individuals in both first- and second-line treatment regimens.
Psychopharmacotherapy in lactating mothers
Breastfeeding should be supported in women with mental health conditions, and the American College of Obstetricians and Gynecologists provide recommendations on psychopharmacotherapy during lactation.[36] If a woman remains stable on a specific medicine during pregnancy, altering pharmacotherapy postnatal is not recommended due to fetal exposure being more significant than exposure through lactation. Factors that should be considered when initiating pharmacotherapy during lactation include the likelihood of drug efficacy and the relative infant dose. While a relative infant dose of less than 10% is generally considered safe, medicine-specific data should always be considered, and medicines for which there are available safety data are preferred over medicines recently introduced. Any personal history of effectiveness should underpin clinical decision making.[36]
First-line treatment is with an antipsychotic drug such as olanzapine or haloperidol, with short-term benzodiazepines such as lorazepam.
Benztropine or diphenhydramine are also indicated when using intramuscular haloperidol at a dose greater than 5 mg to prevent extrapyramidal symptoms and dystonia.
Evidence on the safety of specific drugs during breastfeeding is a rapidly developing field, and there are limited data on the safety of these drugs in the postnatal period.[37] For individual cases where alternative drug options need to be considered, consult consultant advice before prescribing.[37] Further information on pharmacological therapies during lactation are also available online: Drugs and Lactation Database (LactMed) Opens in new window UK Teratology Information Service Opens in new window
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