Phase One Acute Treatment

The first phase of treatment begins with the recognition of acute psychotic symptoms. By definition, these symptoms include some combination of delusions, hallucinations, and thought disorganization. Positive symptoms can be accompanied by agitation, behavioral dyscontrol, and aggressive behavior. The primary goal of treatment in this phase of illness is the rapid resolution of these symptoms. Prompt control of psychosis will reduce the patient's and family's subjective distress, minimize disruption in functional activities such as work or school, and avoid possible danger to the patient or others. Although dosage requirements and time course of response can vary considerably among different patients, there is usually little to be gained by use of megadoses of antipsychotic drugs. Appropriate dosing of both conventional and atypical antipsychotics is critical to optimize the ratio of efficacy to adverse effects (Maixner et al., 1999). Excessively conservative doses will not reach optimal efficacy, and may lead to unnecessary augmentation or polypharmacy, whereas overly aggressive dosing leads to an unnecessary side effect burden and increased risk of noncompliance. The initial suggested dose and optimal dose range of various atypical antipsychotics and haloperi-dol for young, otherwise healthy, patients is summarized in Table 10.5. In first-episode patients, the low end of the suggested dose range is best utilized, whereas in more chronic patients, the upper part of the range is often more appropriate. In elderly patients, one-fourth to half of the recommended young adult dose is often optimal.

Few data are available to suggest that one agent works more rapidly than the others, although this has recently been the subject of clinical study. Similarly, clinical studies have not demonstrated any differences in speed of response among these atypical antipsychotics and conventional neuroleptics. Agitation, aggressive behavior, and motoric hyperactivity tend to respond to treatment within hours to days. Hallucinations and delusions typically take somewhat longer, and although these symptoms may begin to improve within a few days, a full response may require 4 to 8 weeks.

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