Medical Care
Because most cases of alcohol-related psychosis are self-limiting, removal of alcohol should suffice.
The initial treatment of patients with alcohol intoxication or withdrawal should focus on medically stabilizing the patient by assessing respiratory, circulatory, and neurological systems. An intoxicated patient or one undergoing withdrawal to the point with psychosis should be considered a medical emergency because of the risks of unconsciousness, seizures, and delirium. Medical treatment should focus on the effect of alcohol on the body as a whole. A patient with head trauma may be misdiagnosed with Wernicke-Korsakoff syndrome, and a neurologic examination should always be considered. Alcohol withdrawal requires inpatient hospitalization for more than 72 hours after the risk of delirium tremens has subsided.
Alcohol withdrawal psychosis is a symptom of alcohol withdrawal and should be treated in the context of alcohol withdrawal. Treatment is initiated with cautious use of oral or intramuscular benzodiazepines. Lorazepam (Ativan) at 1-2 mg or chlordiazepoxide (Librium) at 25-50 mg PO or IM is used commonly and frequently under the guidance of Clinical Institute Withdrawal Assessment (CIWA) of Alcohol Scale. The dose of benzodiazepine is tapered over the next 5-7 days. Studies have shown promising findings from non-benzodiazepine alternatives to successfully treat alcohol withdrawal. [19]
In the event patients are in danger of harming themselves or others, rapid sedation should be initiated with a high-potency antipsychotic drug such as haloperidol (Haldol) at 5-10 mg PO or IM, frequently given with anticholinergics, benztropine (Cogentin) (1-2 mg) or diphenhydramine (Benadryl) (25-50 mg); both can be given PO or IM to prevent extrapyramidal adverse effects.
Antipsychotics may lower the seizure threshold and should not be used to treat withdrawal symptoms unless absolutely necessary and used in combination with a benzodiazepine or antiseizure medications (eg, valproic acid [Depakote] or carbamazepine [Tegretol]).
Nonmedical treatment includes the use of mechanical wrist and leg restraints if acute danger of assault or self-harm is not managed adequately by chemical restraints alone.
Treatment may include thiamine at 100 mg parentally followed by supplemental thiamine at 100 mg 3 times a day, folic acid at 1 mg, and a daily multivitamin.
In case of a suspected opiate overdose, administer naloxone (Narcan) at 0.4-2 mg IV, IM, SC, or endotracheally.
Outpatient care
A day treatment program or partial hospitalization can be used for those who do not require a highly structured inpatient environment. Daily individual, group, and weekly family therapy provide intensive treatment that is similar to inpatient settings. Programs specifically designed for substance abuse also provide daily substance abuse meetings and education. Medication evaluations and monitoring assure stabilization in the least restrictive environment.
Institute a psychiatric follow-up visit within 2 weeks of the initial evaluation to assure compliance.
Consider a follow-up examination with a neurologist or internal medicine specialist, depending on the complications of alcohol abuse.
Carefully monitor patients for recurring psychosis, depression, and relapse of alcohol use.
Transfer
If psychosis persists past initial treatment, the patient may be suffering from an undiagnosed psychotic disorder, such as schizophrenia or bipolar affective disorder. Inpatient psychiatric hospitalization may be required for diagnosis and psychopharmacological treatment.
If a risk of delirium tremens or suicide is present, transferring the patient to a psychiatric inpatient unit might be required.
A day treatment program or partial hospitalization can be used for those who do not require a highly structured inpatient environment. Daily individual, group, and weekly family therapy is provided. Programs specifically designed for substance abuse also provide daily substance abuse meetings and education. Medication evaluations and monitoring assure stabilization in the least restrictive environment.
Consultations
Neurologist consultation can assist in the evaluation of the patient's neurological status to rule out neurological consequences of alcohol (ie, peripheral neuropathy, Wernicke-Korsakoff syndrome, seizures, postictal states, encephalitis, subdural hematoma).
An internal medicine specialist can provide extended care to patients with a blood dyscrasia, electrolyte abnormality, thiamine deficiency, gastric tumors, or diabetes.
Psychiatrist and social services counselor can assist with inpatient treatment for substance abuse or further psychiatric stabilization. [20]
The patient and family need education about alcohol and referral to Alcoholics Anonymous (AA) and family supports. Social services personnel can help with outpatient services (eg, AA, sober houses, provider appointments). Family issues may be involved, and social services counselors can be helpful in providing supportive and directive care.
Diet
No specific dietary restrictions are necessary. However, if a patient has a thiamine-poor diet, further dietary intake should be normalized.
Activity
A patient intoxicated with alcohol or with severe alcohol withdrawal symptoms frequently has ataxia and can with waxing and waning sensorium and consequently are at risk for falls. Limit the activity of such patients until symptoms have resolved.
Prevention
Prevention is a result of abstinence and is the primary treatment of choice. Some patients may achieve success by attending 90 AA meetings in 90 days.
A sponsor (a recovering alcoholic committed to sobriety) helps provide a support network for attending meetings and seeking community resources.
