BMJ  2007;334:686-692 (31 March), doi:10.1136/bmj.39148.668160.80

Clinical Review

Managing the acute psychotic episode

Early Intervention Team for Ealing, Southall UB2 4EU

The first 150 words of the full text of this article appear below.

People with a first or recurrent psychotic episode tend to present late for medical attention, and many do not present at all. Presentation is often initiated by others, not by patients themselves. Psychosis can also become apparent during a manic presentation, when patients act on their delusions in a public forum, or when they have the complications of substance misuse. Patients who experience intolerable symptoms (distressing delusions or voices; box 1) often seek medical help. In emergency settings, family members' concerns contrast with the patient's apparent indifference. The highest risk of suicide in people with schizophrenia occurs during the first five years of illness ("the critical period"), and interventions are most fruitful during this time. Importantly, patients experiencing their first episode should quickly be given competent assessments and access to appropriate services.

Summary points Acute psychosis is a common psychiatric emergency that may present to health services other than mental health practitioners . . . [Full text of this article]

Sources and selection criteria

Box 1 Positive psychotic symptoms
Clear symptoms (one or more needed for a diagnosis of schizophrenia)
Less clear symptoms (one or more needed for a diagnosis of schizophrenia)

How common is psychosis?

Terminology

How do I diagnose psychosis?

History
Box 2 Negative psychotic symptoms (less clear symptoms; on their own, at least two of these symptoms are needed to diagnose schizophrenia)
Mental state examination
Box 3 Psychiatric differential diagnosis
Collateral history

What else could it be?

Patient's perspective

Which treatment setting?

Additional educational resources
Resources for healthcare professionals
Resources for patients

How do I manage a patient with acute psychosis?

Pharmacotherapy
Box 4 Management principles in acute psychosis
Box 5 Definition of metabolic syndrome¹⁵
Psychosocial
Role of the general practitioner in diagnosis and treatment

What happens next?

Box 6 Relapse and recovery after a psychotic episode
Relapse at one year²⁰
Antipsychotic drug treatment but no psychosocial interventions
Placebo treatment and no psychosocial interventions
Antipsychotic drug treatment and psychosocial intervention(s)
Recovery (defined as global assessment of function >60) at 15-25 years' follow-up⁷

Conclusions

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