Psychosis

---

1st line tx

- !st line is an atypical. Amisulpride, aripiprazole, risperidone, lurisidone, and ziprasidone are favored.

- Olanzapine is not favored for first-line use, despite slightly better efficacy than many non-clozapine antipsychotics, due to high long-term safety risks.

- Quetiapine is also not favored due to significant weight gain and metabolic risks and because it is among the least effective for preventing the next episode.

2nd line tx:

- If stopped d/t intolerance, try an alternative first line SGA.

- If stopped d/t inefficacy, try risperidone, olanzapine, or FGA (perphenazine favored over haloperidol)

3rd line tx:

- Try clozapine.

- Add  risperidone, lamotrigine, or ECT.

- Add memantine or omega3s.

- Try combination of FGA + mirtazapine

1st line tx is an SGA. Amisulpride, aripiprazole, risperidone, and ziprasidone are preferred.

· If poorly tolerated, try an alternative first line drug

· If poor response, try a second-line SGA: risperidone, olanzapine, or a first generation

· If inadequate response, try any SGA or FGA

· If still no improvement, transition to clozapine monotherapy

If still inadequate response, augment with lamotrigine, risperidone, or ECT. Consider adding memantine or omega3s

If unable to complete trial of clozapine, try another antipsychotic monotherapy, eg aripiprazole.

Look at the criteria with your very best Jeff Foxworthy inner voice. (You might be a redneck if…)
You might have a delusional disorder if….

· Delusions are not bizarre. They involve situations that occur in real life.

· Delusions generally last a month or longer.

· Pt does not meet criteria for schizophrenia.

· Behavior is generally normal, not bizarre or odd.

If paranoia and delusions seem to get worse around age 60-70, try to find a family member to collaborate.

· If pt was always a bit paranoid/suspicious, but was able to cover it up, then it might be a delusional disorder.

· If this is fairly new for pt with abrupt onset, consider delirium.

· If this is fairly new for pt with slow and insidious onset, consider that they might be brewing a dementia.

THE BAD NEWS:

Sadly, antipsychotics really don’t work for pure delusional disorder, but try them anyway. Goal is to reduce the distress. 

· If delusions interfere with sleep, try a pinch of quetiapine at HS.

· If they are really bad, try a smidgen of low dose risperidone, also has a nice anxiolytic benefit.

Here’s an interesting factoid: Sometimes adding an antipsychotic makes it seem like they get worse, but it’s often because they were quietly delusional before, and now they are a bit more loose and verbal. May actually be an improvement, so stay the course and cautiously try increasing the dose. But don't get your hopes up and bail if adverse effects mitigate any improvement.   

FGA = first generation antipsychotic, AKA "typical", eg haloperidol, thorazine, et.

SGA = second generation antipsychotic, AKA "atypical", eg risperidone, quetiapine, olanzapine, etc.

ALL:  Risk of neuroleptic malignant syndrome. 

ALL: Risk of tardive dyskinesia. 

ALL have weight gain, risk of diabetes, hyperlipidemia (monitor glucose on all of them)
ALL: Enhance effect of antihypertensives.

Beware the “dines” and the “tines” (ranitiDINE, paroxeTINE, etc.) --> block primary pathways of many antipsychotics --> increased blood levels

Hyperprolactemia: 

· Risperidone is worst. Aripiprazole only antipsychotic that doesn’t increase prolactin (best).

EPS Potential: 

· Worst: risperidone > ziprasidone = olanzapine > quetiapine (best)

QT prolongation: 

· Worst: haloperidol > quetiapine > ziprasidone > risperidone > olanzapine (not bad) > lurasidone (best)   

Sedation: 

· Worst: olanzapine> quetiapine> risperidone > ziprasidone > aripiprazole (best)

Orthostatic hypotension: 

· Worst: Clozapine > quetiapine = olanzapine > risperidone (best)

Cardiovascular toxicity: 

· Worst: quetiapine > olanzapine = risperidone > lurasidone (best)

Constipation, dry mouth, urinary hesitancy: 

· Worst: quetiapine > risperidone = olanzapine > ziprasidone (best)

Hyperlipidemia:

· Worst: clozapine > olanzapine > risperidone > ziprasidone > aripiprazole (best) 

Smoking caveat:

· Olanzapine binds to tar in cigarettes. Nicotine patch won’t prevent this. If pt stops smoking, beware of EPS. Cut dose by half.

Gender: 

· Olanzapine better metabolized in women than in men, women can go with lower doses and still get a decent effect.

Olanzapine: 2.5mg BID if they are good sturdy Norwegians. Lower them to 2.5mg qHS if they are in the 90/90 club (older than 90 or weigh less than 90).

Risperidone: 0.25mg BID for GSN, 0.125mg BID for 90/90

Aripiprazole: 2.5mg daily for GSN, 1-2mg for 90/90

Ziprasidone: 20mg BIDWM for GSN, titrate to 40mg.

Lurasidone: 40mg qHS, titrate to 60mg

Quetiapine 25mg qHS for GSN; 12.5mg QID for 90/90, 6.25mg QID if they have parkinsons

Haloperidol: 0.5mg BID for GSN, 0.25mg for 90/90, avoid in parkinsons 

OR, you can do this:

Take the smallest pill that it comes in, and cut it in half if they are GSN, or into quarters if they are in the 90/90 club. That works too. 

GSN = Good Sturdy Norwegians. AKA "well-nourished". Think solid, plump, fluffy.  I am a proud GSN. 

90/90 club = older than 90, or weigh less than 90lbs. Think thin and frail. So skinny they have to run around in the shower to get wet.