Remote Primary Health Care Manuals

Psychosis

  • Condition of the mind that is defined as a loss of contact with reality — affects a person's thinking, talking, behaviour and mood
  • Can be due to a number of mental health problems — schizophrenia, bipolar disorder, severe depression, alcohol/drug misuse, dementia
  • Some physical conditions can look like psychosis, eg epilepsy, delirium

Signs and symptoms may include

  • Delusions — strongly held false beliefs that are not true of a person's cultural or religious background
  • Hallucinations, auditory, visual and sensory — hears, sees, tastes, smells or feels things that are not really present
  • Thought disorganisation — not able to think straight, conversation hard to follow
  • Severe agitation, restlessness, anxiety, hostility, aggression, paranoia

Seek advice

  • For advice on talking with person who may have mental illness — see Mental health assessment
  • Some experiences can be culturally explained — important to ask ATSIHP or family member for advice
  • For help with immediate management and risk mitigation — medical/mental health team consult
Red Flags — Urgent Medical Consult
  • Very agitated or disturbed — see Mental health emergency
  • Threatening self-harm — see Suicidexref-slash icon
  • Neuroleptic malignant syndrome, extra pyramidal side effects
  • Acutely unwell and major risks identified —transfer to hospital

Acute management

Ask

  • Assess risk of harm to others or self — driven by delusions or hallucinations
    • Delusions or beliefs that may lead to the person harming themself or others
    • Auditory hallucinations (voices) or other perceptual experiences (eg command hallucinations) that may drive the person to harm self or others

Check

Only if possible and safe

  • Calculate age-appropriate REWS
    • Adult — AVPU, RR, O2 sats, pulse, BP, Temp
    • Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • U/A, pregnancy test
  • ECG
  • Coma scale
    • Head-to-toe exam — with attention to head injury, infection (eg chest, ear, UTI), epilepsy (fits), encephalitis, medicine toxicity, electrolyte imbalance, thyroid dysfunction

Do

  • Mental health assessment
  • FBC, ESR, UEC, LFT, TFT, HbA1c, lipids, hepatitis, HIV, syphilis serology, urine drug screen, urine ACR

Antipsychotic medicines

  • Oral medicines are first choice when managing psychosis
    • Tablets work quicker, eg some calming effects often in a few hours
  • Need for long-term medicine usually decided by psychiatrist — can include oral tablets or depot injections
    • Effects may take several days or weeks
  • Always check manufacturer's directions for preparing and giving depot medicines
  • Some adverse effects of antipsychotic medications need urgent medical consult — Table 5.2

Table 5.2   Serious adverse effects

                                                                Urgent Medical Consult

Neuroleptic Malignant Syndrome (NMS) — rare but potentially fatal complication of antipsychotic medicines — medical emergency

Signs and Symptoms

  • High temp, altered consciousness, confusion, muscle stiffness
  • May have fluctuating pulse and BP, fast RR, raised CK

Do

  • Stop all antipsychotic medicines straight away
  • Maintain fluids (hydration)
  • Send to hospital urgently

Extra-pyramidal side effects (EPSE)

Signs and Symptoms

  • Muscular shaking (tremors)
  • Dystonia (muscular spasms) including spasm of larynx 
  • Parkinsonism (muscular stiffness, rigidity)
  • Akathisia (restlessness, agitation)
  • Dyskinesia (involuntary twisting/squirming, mouth/tongue movements)
  • Oculogyric crisis (eyes up, hard to look down, bending back of head, grimace)
  • Hypersalivation (drooling, dribbling)

Do

  • Give benzatropine IM — adult 1–2mg, single dose
  • Symptoms should resolve in 15 minutes

Ongoing management 

  • Usually multi-professional and multi-service provider approach
  • Medical follow-up to make management plan, mental health care plan — to help support person to stay in community
    • Must include relapse prevention strategies, physical health, psychological health, social and environmental health, support for carers, legal considerations
  • Antipsychotic medicines increase risk of metabolic syndrome (group of conditions that increase risk of chronic disease) — see Combined checks for chronic conditions 
  • If woman has changes in menstrual cycle, swollen/tender breasts and galactorrhoea (milk from breasts when not breastfeeding) — check blood prolactin levels