Doctors Revision

Mental Health & Substance Use

Psychosis

A mental health condition characterized by a loss of contact with reality, involving distortions in thinking (delusions), perception (hallucinations), emotions, and behavior. Can be acute or chronic (e.g., Schizophrenia).

Also known as: Psychotic Disorder, Schizophrenia (if chronic)

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Referral and warning signs

When to refer

Refer to specialist (Mental Health specialist/Psychiatrist - HC4/H/RR) for: First episode of psychosis (for diagnosis, initiation of treatment, ruling out organic causes). Treatment resistance or poor response. Management of significant side effects. Need for Clozapine or LAI initiation. Complex comorbidities (e.g., substance use). Diagnostic uncertainty.

Red flags

  • First episode of psychosis
  • Sudden onset of severe psychosis
  • Command hallucinations instructing harm to self or others
  • Severe agitation or aggression posing risk
  • Catatonia
  • Suspicion of organic cause (e.g., fever, neurological signs, substance intoxication)

Signs and symptoms

  • Positive Symptoms (Presence of abnormal experiences):
  • - Delusions: Fixed, false beliefs firmly held despite evidence to the contrary (e.g., persecutory, grandiose, religious, somatic, bizarre).
  • - Hallucinations: Sensory experiences without external stimuli (most common are auditory - hearing voices, but can be visual, tactile, olfactory, gustatory).
  • - Disorganized Thinking/Speech: Loose associations, tangentiality, incoherence ('word salad'), neologisms.
  • - Disorganized or Catatonic Behavior: Agitation, unpredictable behavior, inappropriate silliness, stereotyped movements, or marked decrease in reactivity (catatonia - stupor, rigidity, posturing, mutism).
  • Negative Symptoms (Absence or reduction of normal functions):
  • - Affective Flattening: Reduced range and intensity of emotional expression (blunted affect, mask-like face).
  • - Alogia: Poverty of speech (reduced amount) or poverty of content (vague, empty speech).
  • - Avolition/Apathy: Lack of motivation, inability to initiate or persist in goal-directed activities.
  • - Anhedonia: Loss of interest or pleasure.
  • - Asociality: Social withdrawal.
  • Cognitive Symptoms: Impaired attention, memory, executive function (planning, problem-solving).
  • Mood Symptoms: Depression, anxiety, irritability, inappropriate affect.
  • Functional Impairment: Deterioration in work, social relationships, self-care.

Risk factors

  • Genetic predisposition / Family history (strongest for schizophrenia).
  • Biological factors (neurotransmitter imbalance - dopamine hypothesis, glutamate).
  • Environmental factors (prenatal factors like infection/malnutrition, obstetric complications, cannabis use in adolescence, urban living, migration, psychosocial stress).
  • Substance abuse (can trigger psychosis or mimic symptoms).
  • Certain medical conditions (delirium, dementia, infections, autoimmune disorders, endocrine disorders, brain tumors).

Diagnosis

Clinical assessment

Diagnosis based on clinical interview with patient and collateral information (family/carers). Assess for characteristic positive and negative symptoms, duration of symptoms, functional decline. Rule out psychosis due to a general medical condition, substance intoxication/withdrawal, or mood disorder with psychotic features.

Investigations

  • Good social, personal, family history.
  • Mental state examination.
  • Physical examination and investigations to rule out organic causes:
  • - Toxicology screen (urine/blood) for substance use.
  • - Basic labs: CBC, electrolytes, renal function, liver function, glucose.
  • - Consider: Thyroid function tests, RPR/VDRL (syphilis), HIV test, autoimmune screen, Brain imaging (CT/MRI - esp. for first episode or atypical presentation).

Diagnostic criteria

Based on diagnostic criteria (e.g., DSM-5, ICD). Schizophrenia requires characteristic symptoms present for significant duration (e.g., ≥6 months) with social/occupational dysfunction. Brief Psychotic Disorder (<1 month), Schizophreniform Disorder (1-6 months), Schizoaffective Disorder (psychosis + mood episodes), Delusional Disorder also exist.

Management

Non-pharmacological management

  • Psychoeducation (patient and family): Understanding illness, treatment, relapse prevention.
  • Supportive environment.
  • Psychosocial interventions (adjunctive): Family therapy, Social skills training, Cognitive Behavioral Therapy for psychosis (CBTp), Vocational rehabilitation.
  • Ensure safety (manage risk of harm to self or others).
  • Regular follow-up and continuity of care.
  • Community-based rehabilitation services.

Pharmacological treatment

  • Antipsychotic Medications (Mainstay of treatment): Reduce positive symptoms, prevent relapse.
  • - Acute Psychosis:
  • - Choice often based on availability, side effect profile, patient preference. Examples:
  • - Haloperidol: 5-10mg PO/IM daily initially (lower in elderly), maintenance 5-20mg/d divided.
  • - Chlorpromazine: 75-150mg PO/IM daily initially, maintenance 75-300mg/d (up to 1000mg/d for severe).
  • - Risperidone: 2mg PO daily initially, titrate up to 4-8mg/d divided.
  • - Olanzapine: 5-10mg PO daily initially, maintenance 10-20mg/d.
  • - Quetiapine: Titrate up to 150-750mg/d divided.
  • - Use one antipsychotic at a time. Adjust dose based on response over 4-6 weeks.
  • - Chronic Psychosis / Maintenance:
  • - Continue antipsychotic that was effective acutely, at lowest effective dose.
  • - Consider Long-Acting Injectable (LAI) Antipsychotics if adherence is poor or patient prefers: Fluphenazine decanoate (12.5-50mg deep IM q2-5 weeks), Haloperidol decanoate (50-300mg deep IM q3-4 weeks), Zuclopenthixol decanoate (200-500mg deep IM q4 weeks). Risperidone LAI, Paliperidone LAI, Aripiprazole LAI also available (RR/NR).
  • - Treatment-Resistant Schizophrenia (failure of ≥2 antipsychotics): Clozapine (requires strict blood monitoring for agranulocytosis - NR level).
  • Management of Extrapyramidal Side Effects (EPS - rigidity, tremor, dystonia, akathisia):
  • - Add anticholinergic: Benzhexol (Trihexyphenidyl) 2mg PO q12h PRN or scheduled, then reduce gradually.
  • - Consider switching to antipsychotic with lower EPS risk (e.g., atypical).
  • Follow specific Ugandan treatment algorithms/guidelines.

Monitoring

Monitor symptoms (positive, negative, cognitive, mood). Monitor functional status. Monitor for side effects: EPS, weight gain, metabolic syndrome (glucose, lipids - esp. with atypicals), sedation, anticholinergic effects, QTc prolongation, prolactin elevation, agranulocytosis (Clozapine). Monitor adherence. Assess suicide risk.

Complications

  • Relapse of psychosis
  • Suicide
  • Substance abuse
  • Homelessness, unemployment, poverty
  • Social isolation
  • Medical comorbidities (cardiovascular, metabolic disease - increased risk)
  • Reduced life expectancy
  • Stigma and discrimination

Prevention

  • Primary prevention largely unknown.
  • Secondary prevention: Early detection and intervention in first-episode psychosis improves long-term outcome. Maintenance antipsychotic treatment significantly reduces relapse risk.
  • Tertiary prevention: Rehabilitation, psychosocial support to reduce disability and improve quality of life.

Patient education

  • Explain the nature of psychotic illness.
  • Discuss the role of medication in managing symptoms and preventing relapse.
  • Educate on potential side effects and importance of reporting them.
  • Stress critical importance of medication adherence, even when feeling well.
  • Explain the role of psychosocial support and rehabilitation.
  • Educate family on how to support the patient and recognize early signs of relapse.
  • Address stigma.

Uganda-specific notes

Psychosis is often attributed to supernatural causes, leading to delays in seeking medical care and stigma. Differentiating from organic delirium (e.g., from malaria, HIV, infections) is crucial. First-generation antipsychotics (Haloperidol, Chlorpromazine) and LAIs (Fluphenazine, Haloperidol) are more widely available than newer atypicals. Clozapine access and monitoring capacity are very limited. Community-based mental health services and psychosocial support are often scarce.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 9, Section 9.2.4

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