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Advise the patient with psychosis• Educate the patient and carer/family about the condition: the patient with psychosis often lacks insight into the illness and may be hostile towards carers and health care workers. S/he mayhave difficulty functioning, especially in high stress environments.• Emphasize the importance of adherence with medication.• Encourage patient to resume social, educational and work activities as appropriate. Work with local agencies to find educational or employment opportunities.• Explore housing/assisted living support if needed and available.• Refer for support group and cognitive behavioural therapy if available.• Liaise with available health and social resources to provide support for the family and refer for family therapy if available.• People with psychosis are often discriminated against. Always consider protection of the patient’s human rights and the need to avoid institutional care.Dr Treat the patient with psychosis• Refer the patient with bipolar disorder to a psychiatrist for care.• Initiation, titration and withdrawal is best done by a psychiatrist.• Use intramuscular antipsychotic medication if patient is not adherent to oral medication and needs long term treatment.Drug Starting dose Maintenance dose NoteHaloperidol 1.5–10mg oral as a single dose or in 2 divided doses. If > Usually 2–10mg per day.Minimal anticholinergic side effects.60 years start at lower dose and increase more gradually.Chlorpromazine 25mg oral twice daily Usually 75–300mg daily but 1000mg may be needed. Once symptoms One of the most sedating antipsychotics.are controlled, give as a single bedtime dose.Fluphenazine decanoate 12.5mg deep intramuscular injection Usually 25–50mg every 4 weeks. Full response can take 2 monthsFewer anticholinergic side effects than chlorpromazine.Flupenthixol decanoate 20mg deep intramuscular injection Usually 60mg every 4 weeks. Full response can take 2 months.Fewer anticholinergic side effects than chlorpromazine.Zuclopenthixol decanoate 100mg deep intramuscular injection Usually 200–400mg every 4 weeks. Full response can take 2 months.Fewer anticholinergic side effects than chlorpromazine.Refer if any side effects develop on antipsychotic medication• Anticholinergic side effects: dry mouth, blurred vision, constipation, urinary retention, worsening of closed angle glaucoma• Extrapyramidal side effects:--Acute dystonic reactions (often painful muscle spasms) may appear within 24-48 hours of starting medication. Give biperiden 2mg IM, repeat every 30 minutes to maximum 4 doses in24 hours. Refer patient same day for further management.--Parkinsonian signs (bradykinesia, tremor, rigidity) may occur after weeks or months on treatment, more commonly in elderly patients. Give orphenadrine 50mg up to 3 times a day.--Akathisia (motor restlessness) may occur after days or weeks of treatment.--Tardive dyskinesia (persistent involuntary movements) may occur after months (usually more than 6 months) of treatment.85