Psychiatric Treatment Dr.Safeyya Adeeb Alchalabi

Acute psychosis If the first treatment fails first episode of schizophrenic psychosis atypical antipsychotic or low-dose typical antipsychotic If the first treatment fails review compliance and tolerability poor or no response over 6—8 weeks switch to another drug assess over a further 6 weeks

Acute psychosis clozapine should be considered patient with a previous history of schizophrenia experiences a relapse adherence to treatment should be assessed thoroughly social and psychological precipitants If adherence to medication is doubtful continue with the usual drug treat­ment + short-term sedative If adherence is deemed satisfactory switch to a different antipsychotic assess over the following 6 weeks If 6 weeks of this second antipsychotic treatment proves ineffective clozapine should be considered

Acute disturbed or violent behaviour Try non-drug measures Seclusion talking down privacy quiet Offer oral treatment Haloperidol 5 mg Olanzapine 10 mg Risperidone 1—2 mg + Lorazepam 1—2 mg Consider i.m. treatment Lorazepam 1—2 mg Olanzapine 5—10 mg Diazepam 10 mg over at Least 5 minutes Consider i.v, treatment

Acute dystonia treatment Abrupt onset of muscle spasm hours after commencing an antipsychotic particularly after a typical drug can be very alarming especially on first exposure to antipsychotics It is more common in the young than tne old it causes respiratory stridor and tongue protrusion it can induce panic treatment should stop the antipsychotic give procyclidine 5—10 mg or equivalent intramuscularly One should check for cyanosis, and administer oxygen and transfer to a medical unit as required

Acute dystonia

Acute dystonia

Acute dystonia

Neuroleptic malignant syndrome (NMS) NMS is a rare idiosyncratic reaction to antipsychotics characterized by intense extrapyramidal rigidity dystonias pyrexia autonomic dysfunction diaphoresis clouding of consciousness

Neuroleptic malignant syndrome (NMS)

Neuroleptic malignant syndrome (NMS)

Neuroleptic malignant syndrome (NMS) NMS has been associated larger doses high-potency typical antipsy-chotics

Treatment of neuroleptic malignant syndrome Transfer to acute medical ward or intensive care unit Monitor ECG blood pressure renal status Cessation of neuroleptics Bromocriptine 5—10 mg orally three times daily if unable to swallow Apomorphine infusion 1 mg/h s.c. no response Dantrolene sodium 50 mg twice daily maximum for 3 days

Mortality associated with NMS Lower with atypical antipsychotics autonomic instability (e.g. cardiac arrest) renal failure due to rhabdornyolysis and myoglobinuria

ECT severe depressive illness, catatonia, prolonged or severe mania. The National Institute for Health and Clinical Excellence (NICE) guidance on ECT recommends that it be restricted to: severe depressive illness, catatonia, prolonged or severe mania. postpartum psychoses. NMS

severe depressive illness treatment resistant psychomotor retardation psychotic features such as delusions and/or hallucinations life-saving if the patient is very acutely suicidal fails to main­tain adequate nutrition or hydration

severe depressive illness patient preference past history of response to ECT the need for a rapid response to treatment the risks of other treatments exceed those for ECT elderly who have not responded to drug treatments or have suffered unpleasant side effects Remission rates in clinical trials are 60—70 per cent

mania prolonged or severe mania if patients have drug-resistant the need for a speedy therapeutic response as a safe alternative to high-dose medica­tions if patients have drug-resistant 'rapid cycling' mania

Schizophrenia catatonic excitement or immobility the patient cannot tolerate medications failed to respond to adequate doses of antipsychotics including clozapine

ECT

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