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

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ACUTE
|
able to accept or tolerate oral treatment
|
males and nonlactating females
1st line – 

oral second-generation antipsychotic drug + psychosocial support

These patients may present to the physician's office or the emergency room. Oral antipsychotics should be offered as first-line treatment to all patients unless they are unable to tolerate or take oral medications.

At presentation it is not known what the diagnosis is, and the psychotic symptoms are treated with antipsychotic medications. 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 nonpharmacologic treatments, which may be influenced by cultural and religious origins.[34]

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 nonlactating females
Consider – 

oral lorazepam

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 nonlactating females
2nd line – 

oral first-generation antipsychotic drug + psychosocial support

These patients may present to the physician's office or the emergency room. Oral antipsychotics should be offered as first-line treatment to all patients unless they are unable to tolerate or take oral medications.

Diagnosis is unknown at presentation, and the psychotic symptoms are treated with antipsychotic medications. 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 nonpharmacologic 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 benztropine

Back
ACUTE
|
able to accept or tolerate oral treatment
|
males and nonlactating females
Plus – 

oral benztropine

Treatment recommended for ALL patients in selected patient group

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

Benztropine is often prescribed for tremors.

Primary options

benztropine: 1-2 mg orally two to three times daily

Consider – oral lorazepam

Back
ACUTE
|
able to accept or tolerate oral treatment
|
males and nonlactating females
Consider – 

oral lorazepam

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 physician's office or the emergency room.

If a woman remains stable on a specific medication during pregnancy, altering pharmacotherapy postpartum 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, medication-specific data should always be considered, and medications for which there are available safety data are preferred over medications 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 breast-feeding is a rapidly developing field, and there are limited data on the safety of these drugs in the postpartum period.[37]​ For individual cases where alternative drug options need to be considered, consult specialist advice before prescribing.[37]​ Further information on pharmacologic 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.[38]​ 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 nonpharmacologic treatments, which may be influenced by cultural and religious origins.[34]

refusing or unable to tolerate oral medication

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

Back
ACUTE
|
refusing or unable to tolerate oral medication
|
male or nonlactating female
1st line – 

intramuscular second-generation antipsychotic drug + psychosocial support

These patients may be acutely agitated, presenting in the emergency room setting.

Second-generation antipsychotic drugs are first-line treatment. This is because of their lower risk of extrapyramidal adverse effects, which occur at high rates in people never treated with antipsychotic medications.

Once the patient is stabilized, oral medication can be substituted. Intramuscular antipsychotic treatment should be replaced with oral antipsychotic medication 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 nonpharmacologic 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 medication
|
male or nonlactating female
Consider – 

intramuscular lorazepam

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 medication
|
male or nonlactating female
2nd line – 

intramuscular first-generation antipsychotic drug + psychosocial support

These patients may be acutely agitated, presenting in the emergency room 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 medication 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 nonpharmacologic 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 – benztropine or diphenhydramine

Back
ACUTE
|
refusing or unable to tolerate oral medication
|
male or nonlactating female
Plus – 

benztropine or diphenhydramine

Treatment recommended for ALL patients in selected patient group

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

Primary options

benztropine: 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 medication
|
male or nonlactating female
Consider – 

intramuscular lorazepam

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 medication
|
lactating female
1st line – 

antipsychotic drug + psychosocial support

These patients may be acutely agitated, presenting in the emergency room setting.

If a woman remains stable on a specific medication during pregnancy, altering pharmacotherapy postpartum 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, medication-specific data should always be considered, and medications for which there are available safety data are preferred over medications 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 medication.[36]​ Evidence on the safety of specific drugs during breast-feeding is a rapidly developing field, and there are limited data on the safety of these drugs in the postpartum period.[37]​ For individual cases where alternative drug options need to be considered, consult specialist advice before prescribing.[37]​ Further information on pharmacologic 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 nonpharmacologic 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