1. Psychiatric Treatment
Dr.Safeyya Adeeb Alchalabi

2. 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

3. 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

4. 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

5. 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

6. Acute dystonia

7. Acute dystonia

8. Acute dystonia

10. 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

11. Neuroleptic malignant syndrome (NMS)

12. Neuroleptic malignant syndrome (NMS)

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

16. 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

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

19. 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

20. 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

21. 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

22. 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

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

25. ECT

33. Thank you