Medication Summary
The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Both typical and atypical antipsychotic agents have been used in the treatment of brief psychotic disorder.
Antipsychotics
Class Summary
Antipsychotics are high-potency agents that provide rapid, predictable, and effective sedation in the management of patients who are acutely psychotic. They are less sedating and more easily titrated than lower-potency agents but more likely to cause extrapyramidal syndrome (EPS). They are often combined in the same syringe with a benzodiazepine to improve sedation and anxiety and reduce dystonia or akathisia. For prophylaxis of EPS, temporary use of a serotonin-dopamine antagonist may be needed.
Antipsychotics may be administered intramuscularly (IM) or intravenously (IV). In a nonemergency setting, haloperidol may be given orally. Haloperidol also has a monthly depot form (haloperidol decanoate), but this is not useful for brief psychotic disorder, because of the short duration of the psychotic episode.
Haloperidol (Haldol)
Haloperidol controls psychosis and provides rapid tranquilization. It can be administered with a benzodiazepine to protect against a lowered seizure threshold. IV haloperidol can be used effectively to treat acute psychotic agitation in a low dosage of 1-2 mg every 8 hours for 2-3 days, and the drug can be continued orally for the next several days until symptoms completely subside. In cases where it is difficulty to differentiate brief psychotic disorder and delirium, it should be kept in mind that IV haloperidol is also effective for delirium.
Thiothixene
Thiothixene blocks postsynaptic blockade of central nervous system (CNS) dopamine receptors, inhibiting dopamine-mediated effects. It provides rapid tranquilization in both oral and IM forms.
Risperidone (Risperdal)
Unlike haloperidol, risperidone has serotonergic blocking effects that alleviate negative symptoms of psychosis (eg, anhedonia, avolition, amotivation, and flat affect). It is well tolerated and has fewer extrapyramidal adverse effects than typical antipsychotics do. Dosages higher than 6 mg/day increase the risk of extrapyramidal effects.
Olanzapine (Zyprexa)
Olanzapine may inhibit serotonin, muscarinic, and dopamine effects. Its efficacy is similar to that of risperidone; it has fewer dose-dependent adverse effects but is more likely to be associated with weight gain.
Quetiapine (Seroquel)
Quetiapine may act by antagonizing dopamine and serotonin effects. Its efficacy is similar to those of risperidone and olanzapine; it has fewer dose-dependent adverse effects and poses less of a concern with regard to weight gain.
Paliperidone (Invega)
Paliperidone is the major active metabolite of risperidone and the first oral agent that can be given once daily. It is indicated for treatment of acute schizophrenia. The mechanism of action is not completely understood but is thought to involve mediation of central receptor antagonism of dopamine type 2 (D2) and serotonin type 2 (5-HT2A). It also elicits antagonist activity at alpha1- and alpha2-adrenergic receptors and histamine-1 receptors. It has no affinity for cholinergic, muscarinic, or beta-adrenergic receptors.
