Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

able to accept or tolerate oral treatment

1st line – oral second-generation antipsychotic drug + psychosocial support

Back
ACUTE
|
able to accept or tolerate oral treatment
|
males and non-lactating females
1st line – 

oral second-generation antipsychotic drug + psychosocial support

These patients may present to the clinic or the accident and emergency department. Oral antipsychotics should be offered as first-line treatment to all patients unless they are unable to tolerate or take oral medicines.

At presentation it is not known what the diagnosis is, and the psychotic symptoms are treated with antipsychotic medicines. In brief psychotic disorder (BPD) all symptoms resolve and the patient returns to normal functioning. In cases of complete symptom resolution, an attempt to taper the antipsychotic and discontinue 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]​ Family support is crucial to help assure structure and safety to patients who may be experiencing psychotic symptoms for the first time. However, it is important to identify individual perceptions and needs for non-pharmacological treatments, which may be influenced by cultural and religious origins.[34]

In 2017 the European Medicines Agency (EMA) refused to approve marketing authorisation for the antipsychotic iloperidone as its benefits were not considered to outweigh its risks. The EMA considers the drug's effectiveness to be modest. There were concerns about its delayed (2-3 week) onset of action. A significant risk of QT prolongation was noted, particularly in patients taking other specific medications concurrently.[38] Iloperidone is still approved by the US Food and Drug Administration, and it is available for use within other non-European Union countries.

Primary options

olanzapine: 2.5 to 10 mg orally once daily initially, increase by 5 mg/day increments at weekly intervals according to response, maximum 20 mg/day

OR

risperidone: 0.5 to 3 mg/day orally given in 1-2 divided doses, increase by 1-2 mg/day increments at weekly intervals according to response, maximum 8 mg/day

OR

quetiapine: 25 mg orally (immediate release) twice daily initially, increase by 150 mg/day increments on the second and third days with a target dose of 300-400 mg/day by day 4, increase further according to response every 1-2 days, maximum 800 mg/day

OR

ziprasidone: 20 mg orally twice daily initially, increase according to response, maximum 160 mg/day

OR

aripiprazole: 10-15 mg orally once daily initially, increase according to response, maximum 30 mg/day

OR

paliperidone: 6 mg orally once daily initially, increase according to response, maximum 12 mg/day

OR

iloperidone: 1 mg orally twice daily on day 1, increase to 2 mg twice daily on day 2, then increase by 2 mg/day twice daily according to response, maximum 24 mg/day

OR

asenapine: 5 mg sublingually twice daily, increase according to response, maximum 20 mg/day

OR

lurasidone: 40 mg orally once daily, increase according to response, maximum 80 mg/day

Consider – oral lorazepam

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ACUTE
|
able to accept or tolerate oral treatment
|
males and non-lactating females
Consider – 

oral lorazepam

Additional treatment recommended for SOME patients in selected patient group

Lorazepam can be given for its anxiolytic effect when there is the need for rapid sedation of violent or agitated individuals.

Primary options

lorazepam: 1-2 mg orally every 8 hours when required

2nd line – oral first-generation antipsychotic drug + psychosocial support

Back
ACUTE
|
able to accept or tolerate oral treatment
|
males and non-lactating females
2nd line – 

oral first-generation antipsychotic drug + psychosocial support

These patients may present to the clinic or the accident and emergency department. Oral antipsychotics should be offered as first-line treatment to all patients unless they are unable to tolerate or take oral medicines.

Diagnosis is unknown at presentation, and the psychotic symptoms are treated with antipsychotic medicines. In brief psychotic disorder (BPD) all symptoms resolve and the patient returns to normal functioning within 1 month of onset. In cases of complete symptom resolution, an attempt to taper and discontinue the antipsychotic drug should be considered, and treatment is generally not needed past 1 month.

Psychosocial treatments (psychotherapy and family support) should be offered to all people presenting with BPD.[33]​ Family support is crucial to help assure structure and safety to people who may be experiencing psychotic symptoms for the first time. However, it is important to identify individual perceptions and needs for non-pharmacological treatments, which may be influenced by cultural and religious origins.[34]

Primary options

haloperidol: 2-15 mg/day orally given in 2-3 divided doses initially, maximum 20 mg/day

OR

chlorpromazine: 40-100 mg/day orally (immediate release) in 2-4 divided doses, increase by 20-50 mg/day increments every 3-4 days according to response, maximum 800 mg/day

OR

perphenazine: 16-32 mg/day orally in 2-4 divided doses initially, increase according to response; maximum 64 mg/day

OR

fluphenazine: 2-10 mg/day orally given in 2-4 divided doses initially, increase according to response at weekly intervals; maximum 40 mg/day

OR

trifluoperazine: 4-20 mg/day orally given in 2 divided doses initially; maximum 30 mg/day

OR

loxapine: 20-50mg/day orally given in 2 divided doses initially; maximum 100 mg/day

Plus – oral benzatropine

Back
ACUTE
|
able to accept or tolerate oral treatment
|
males and non-lactating females
Plus – 

oral benzatropine

Treatment recommended for ALL patients in selected patient group

Extra-pyramidal adverse effects are common with first-generation antipsychotic drugs. Prophylactic treatment (e.g., benzatropine) can be given to reduce these adverse effects.

Benzatropine is often prescribed for tremors.

Primary options

benzatropine mesilate: 1-2 mg orally two to three times daily

Consider – oral lorazepam

Back
ACUTE
|
able to accept or tolerate oral treatment
|
males and non-lactating females
Consider – 

oral lorazepam

Additional treatment recommended for SOME patients in selected patient group

Lorazepam can be given for its anxiolytic effect when there is the need for rapid sedation of violent or agitated individuals.

Primary options

lorazepam: 1-2 mg orally every 8 hours when required

1st line – antipsychotic drug + psychosocial support

Back
ACUTE
|
able to accept or tolerate oral treatment
|
lactating females
1st line – 

antipsychotic drug + psychosocial support

These patients may present to the clinic or the accident and emergency department.

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.[36]​ 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

Psychosocial treatments (psychotherapy and family support) should be offered to all people presenting with BPD.[39]​ Family support is crucial to help assure structure and safety to people who may be experiencing symptoms for the first time. However, it is important to identify individual perceptions and needs for non-pharmacological treatments, which may be influenced by cultural and religious origins.[34]​ 

refusing or unable to tolerate oral treatment

1st line – intramuscular second-generation antipsychotic drug + psychosocial support

Back
ACUTE
|
refusing or unable to tolerate oral treatment
|
male or non-lactating female
1st line – 

intramuscular second-generation antipsychotic drug + psychosocial support

These patients may be acutely agitated, presenting in the accident and emergency department setting.

Second-generation antipsychotic drugs are first-line treatment. This is because of their lower risk of extra-pyramidal adverse effects, which occur at high rates in people who have never been treated with antipsychotic medicines before.

Once the patient is stabilised, oral medicine can be substituted. Intramuscular antipsychotic treatment should be replaced with oral antipsychotic medicine within 3 days.

Psychosocial treatments (psychotherapy and family support) should be offered to all people presenting with brief psychotic disorder.[33]​ Family support is crucial to help assure structure and safety to people who may be experiencing psychotic symptoms for the first time. However, it is important to identify individual perceptions and needs for non-pharmacological treatments, which may be influenced by cultural and religious origins.[34]

Primary options

olanzapine: 5-10 mg intramuscularly as a single dose initially, a second dose may be given 2 hours later if required, maximum 30 mg/day

OR

aripiprazole: 5.25 to 9.75 mg intramuscularly as a single dose initially, a second dose may be given 2 hours later if required, maximum 30 mg/day

OR

ziprasidone: 10-20 mg intramuscularly as a single dose initially, may repeat 10 mg every 2 hours or 20 mg every 4 hours if required, maximum 40 mg/day

Consider – intramuscular lorazepam

Back
ACUTE
|
refusing or unable to tolerate oral treatment
|
male or non-lactating female
Consider – 

intramuscular lorazepam

Additional treatment recommended for SOME patients in selected patient group

Lorazepam can be given for its anxiolytic effect when there is the need for rapid sedation of violent or agitated individuals.

Primary options

lorazepam: 1-2 mg intramuscularly as a single dose; repeat every 8 hours if required

2nd line – intramuscular first-generation antipsychotic drug + psychosocial support

Back
ACUTE
|
refusing or unable to tolerate oral treatment
|
male or non-lactating female
2nd line – 

intramuscular first-generation antipsychotic drug + psychosocial support

These patients may be acutely agitated, presenting in the accident and emergency department setting.

Haloperidol is a first-generation antipsychotic drug but should only be given at the lowest possible dose.

Intramuscular antipsychotic treatment should be replaced with oral antipsychotic medicine within 3 days.

Psychosocial treatments (psychotherapy and family support) should be offered to all people presenting with brief psychotic disorder.[33]​ Family support is crucial to help assure structure and safety to people who may be experiencing psychotic symptoms for the first time. However, it is important to identify individual perceptions and needs for non-pharmacological treatments, which may be influenced by cultural and religious origins.[34]

Primary options

haloperidol lactate: 0.5 to 5 mg intramuscularly as a single dose, repeat every 4-8 hours if required, maximum 100 mg/day

Plus – benzatropine or diphenhydramine

Back
ACUTE
|
refusing or unable to tolerate oral treatment
|
male or non-lactating female
Plus – 

benzatropine or diphenhydramine

Treatment recommended for ALL patients in selected patient group

Extra-pyramidal adverse effects are common with first-generation antipsychotic drugs. Prophylactic treatment with benzatropine or diphenhydramine can be given to reduce these adverse effects.

Primary options

benzatropine mesilate: 1-2 mg intramuscularly two to three times daily

OR

diphenhydramine: 10-50 mg intramuscularly as a single dose

Consider – intramuscular lorazepam

Back
ACUTE
|
refusing or unable to tolerate oral treatment
|
male or non-lactating female
Consider – 

intramuscular lorazepam

Additional treatment recommended for SOME patients in selected patient group

Lorazepam can be given for its anxiolytic effect when there is the need for rapid sedation of violent or agitated individuals.

Primary options

lorazepam: 1-2 mg intramuscularly as a single dose; repeat every 8 hours if required

1st line – antipsychotic drug + psychosocial support

Back
ACUTE
|
refusing or unable to tolerate oral treatment
|
lactating female
1st line – 

antipsychotic drug + psychosocial support

These patients may be acutely agitated, presenting in the accident and emergency department setting.

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.These agents are available as intramuscular formulations for patients who refuse or are unable to tolerate oral medicine.[36]​ 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

Psychosocial treatments (psychotherapy and family support) should be offered to all people presenting with brief psychotic disorder.[33]​ Family support is crucial to help assure structure and safety to people who may be experiencing psychotic symptoms for the first time. However, it is important to identify individual perceptions and needs for non-pharmacological treatments, which may be influenced by cultural and religious origins.[34]

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer