Psychosis is a general term for a mental state often said to be a "loss of contact with reality." People suffering from it are said to be psychotic.

People who suffer from psychosis may have hallucinations (seeing, hearing or feeling things that are not there) or delusions (believing something is true even though all the evidence shows that it is false), and may have personality changes and disorganised thinking. This may be result in unusual or odd behaviour, as well as difficulty with normal social contact and not being able to carry out normal activities of daily living.

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Psychosis is the word used when a person loses contact with reality and cannot then cope with normal social situations or needs. Symptoms can include:

• hallucinations (seeing, hearing, smelling or feeling things that aren’t there) 

• delusions (believing something is true even if there is evidence that proves it isn't)

• odd thinking

• lack of insight (not realising that things aren’t right).

Psychosis can occur in many conditions e.g. schizophrenia, bipolar mood disorder (manic-depression), and severe stress. It can also be caused by other conditions such as brain tumours, neurological conditions (e.g. Parkinson’s Disease, Alzheimer’s Disease), blood disorders, and hyperthermia. Other major causes include medicines such as excess alcohol, some prescribed medicines (e.g. anticonvulsants and anticholinergics), and illicit medicines (e.g. cannabis, amphetamines, cocaine and crack, LSD).

Psychosis is a major symptom of schizophrenia. Schizophrenia is usually a life-long illness with a high chance of becoming ill again. The main symptoms include:

• Psychosis (see above)

• hearing your own thoughts spoken aloud

• ‘third person’ hallucinations (thinking someone else is talking about you)

• hallucinations in the form of a "commentary" (hearing someone saying what you are doing and talking about it)

• delusions about touch, smell, feel (e.g. feeling things are crawling under your skin)

• the feeling that someone is taking your thoughts away or putting thoughts into your brain.

Hearing voices, being suspicious, having a flat mood, having delusions and feeling persecuted (or "got at") are also common.

Someone who has schizophrenia suffers from psychosis at some time, but someone who has a psychosis isn’t necessarily schizophrenic. However, antipsychotic medicines may help treat the symptoms regardless of the cause or diagnosis. It is known that there are changes in the structure of the brain in schizophrenia.

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Because everyone is unique, everyone's symptoms are different. So, it's not always clear what the right diagnosis is. Here is a list of some possible causes for the symptoms of psychosis. This is not meant to be a textbook list, just some ideas. Some of these can be very rare indeed. Psychosis is almost always a symptom of something being wrong. To start with, the diagnosis isn't always needed as the symptoms need to be treated anyway.

• Schizophrenia

• Prescribed medicine-induced e.g. some anticonvulsants (at higher doses), rarely with some antidepressants, memantine, treatments for Parkinson's disease (e.g. Sinemet, Madopar), some heart drugs (e.g. beta-blockers), some malaria treatments (e.g. mefloquine), high doses of steroids

• Substance misuse e.g. cannabis, amphetamines, cocaine, methamphetamine, LSD, magic mushrooms

• Psychotic depression

• Acute GAD or Generalised Anxiety Disorder

• Schizoaffective disorder - both schizophrenia and bipolar mood disorder

• Delusional disorder

• Acute mania or hypomania with psychosis

• Alcoholic hallucinosis e.g. stopping alcohol or long-term use of alcohol

• Dementia

• Secondary to epilepsy e.g. TLE (Temporal Lobe Epilepsy)

• Acute brain injury e.g. infections, trauma, stroke

• Brain lesions e.g. sarcoidosis

• Brain degeneration e.g. Dementia

• Brain infections e.g. neurosyphilis

• Brain tumours

• OCD (Obsessive Compulsive Disorder)

• Social anxiety - sometimes schizophrenia can first show as social anxiety

• Metabolic problems e.g. over-active or under-active thyroid, vitamin deficiencies

• Very rare conditions e.g. Wilson's disease etc

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Basically, anyone can get psychosis. See the next question for a list of some things that can cause psychosis.

Psychosis itself is probably mainly caused by an increase in dopamine in some parts of the brain. Dopamine is one of the brain's main chemical messengers. In one area of the brain (the mesocortical) it takes in information (e.g. what you can see, hear, smell, feel) and controls what the brain does with that information. We know that too much dopamine in that area of the brain causes the symptoms of psychosis e.g. hallucinations, delusions, paranoia. We know this because drugs which increase dopamine a lot (e.g. cannabis, amphetamines, some treatments for Parkinson's Disease) can cause psychosis. Symptoms of psychosis will almost always be a symptom of something else, just like insomnia is a symptom of something else.

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The list here includes most of the main options but does not say what works and doesn't. Many may be used in combination. Most herbal and alternative therapies have not really been tested in the same rigorous way that medicines have.

Our aim is to try to help people who are taking medication (or should be) get the right medicine, dose and take it regularly for as long as is right. Any medicines should usually be part of the overall treatment, although some people are quite happy just to stick with drugs or talking treatments. If your medicines are right, then everything else can fall into place. If the medicines are wrong, then they may make the symptoms worse and self-help will not be as useful.

Treatments and help should take into account the person's needs and choices.

Self-help

• Avoiding things that can make it worse e.g. smoking cannabis or taking other illicit drugs.
• Stress can make the symptoms worse
• Not drinking too much caffeine, which can make the symptoms worse and more difficult to treat
• Taking any medicines regularly and reliably
• Eating healthily (perhaps including Omega-3 fatty acids) and taking exercise ("exercise to energise") or being active. Three studies have shown that regular exercise really helps negative symptoms and physical health (although that's easier said than done), but has no effect on positive symptoms (Gorczynski 2010).
• You should have a health check every year by your GP. This is because the illness and medication can put you at a higher risk of gaining weight, diabetes, heart disease high cholesterol etc. So, make sure you have your health check every year as your GP may not always remember

Help from others

• Support from families and friends and services such as supported housing, day care and employment schemes are vitally important help a person cope with the symptoms and reduce the risk of relapse
• Befriending is also really helpful (and as effective as CBT, see below) for many people for as long as it carries on.
• Talking treatments - these can include Cognitive Behavioural Therapy (CBT, which helps people cope with the symptoms), family therapies (to help the person and familes cope better) and arts therapies (to help with negative symptoms). While CBT isn't much help when someone is acutely ill, it may help people who get a bit better with medicines, or where their insight is poor. Counselling and supportive psychotherapy (helpful with support and talking things over) can also be useful but should not usually be used (e.g. NICE and SIGN)
• Having psychosocial therapy, along with medicines, may help people with a first episode (Zhao 2010)
• ECT - Electro-Convulsive Therapy may be useful to help relieve some symptoms of psychosis when other teratments have not helped (Kristensen, 2011)
• Alternative therapies such as aromatherapy, hypnosis or hypnotherapy, homeopathy (treating like with like) can be used in conjunction with (but not relied on to replace) conventional treatments. The evidence for these treatments is not very good, especially in psychosis. All of these can be used in conjunction with other therapies. If they help then that is fine and we wouldn't knock them. Click here for a balanced review of complementary and alternative therapies from the Royal College of Psychiatrists (e.g. Ginkgo, Sage, vitamins, other herbals etc, and some useful links).

Medicines

• Antipsychotics are the main treatments for psychosis and the symptoms of schizophrenia. They should be used as early as possible after symptoms start, as this might prevent the symptoms and illness getting worse. Antipsychotics help the treatment of acute episodes and also to prevent relapse. In someone acutely unwell, they are often used in combination with a sedative, along with reassurance and management to help protect the person from harm.

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If you are prescribed a medicine, then there may be many reasons why that one has been chosen. These might include:

• side effects (which ones are important to you)
• local policies or agreements (such as what your GP surgery uses or agreements in your area)
• national policies (e.g. NICE, SIGN - see last question)
• familiarity (it may be better for prescribers to use medicines they are familiar with)
• relative costs for similar medicines (if two medicines are very similar, why waste money on the more expensive one?)
• personal preference (either yours or your prescriber)
• how bad your symptoms are
• any medicine you might have done well with in the past (as it's more likely to work again)

The main medicine treatment options are listed below. They are divided into "Main medicines" and "Others".

For convenience, the "Main medicines” are those medicines that are officially "approved" to treat the condition or symptoms (www.bnf.org/bnf/) and which are listed in the British National Formulary (BNF). To be listed in the BNF there needs to be good evidence that the medicine works and that the manufacturers have applied for a license (a long and costly exercise). "Others" are those medicines where there is some evidence that they help, but either not enough for a license or that no license has been applied for. These should usually only be used where other standard treatments have failed.  

Main medicines

Phenothiazines

• Chlorpromazine

• Fluphenazine (see also depot and long-acting injections)

• Levomepromazine (previously known as methotrimeprazine)

• Pericyazine

• Perphenazine

• Pipothiazine (see depot and long-acting injections)

• Prochlorperazine

• Promazine

• Thioridazine (discontinued in UK and many countries)

• Trifluoperazine

Butyrophenones

• Benperidol

• Haloperidol (see also depot and long-acting injections)

Thioxanthenes

• Flupentixol (see also depot and long-acting injections)

• Zuclopenthixol (see also depot and long-acting injections)

Diphenylbutylpiperidines

• Fluspirilene (see depot and long-acting injections, only available as an import in the UK)

• Pimozide (restricted use due to side effects)

Benzamides, substituted

• Amisulpride

• Sulpiride

Newer, atypical or second generation antipsychotics

• Aripiprazole

• Clozapine

• Olanzapine

• Paliperidone 

• Quetiapine

• Risperidone  (see also depot and long-acting injections)

• Sertindole (available in Australia))

• Zotepine (rarely used, discontinued in many countries in 2010)

• Asenapine (Sycrest® or Saphris®) - is licensed in USA for psychosis or schizophrenia, but isn't yet in UK)

Depot and long-acting injections

Several of the above medications are available as depot and long-acing injections - these are listed below:

• Flupentixol decanoate (Depixol®)

• Fluphenazine decanoate (Modecate®)

• Fluspirilene (Redeptin®, only available if imported into UK)

• Haloperidol decanoate (Haldol Decanoate®)

• Olanzapine pamoate (Zypadhera®)

• Paliperidone palmitate (Xeplion®)

• Pipotiazine palmitate (Piportil®)

• Zuclopenthixol acetate (Clopixol-Acuphase®)

• Zuclopenthixol decanoate (Clopixol®)

• Risperidone  (Risperdal Consta®)

Quite a choice eh?

It is generally considered that the newer atypical or second-generation antipsychotics (SGA) are overall better than the older ones. However, two large independent studies (no drug companies involved!) published in 2005 and 2006 called CATIE and CUtLASS have shown that the antipsychotics seem to be as effective as each other but with DIFFERENT side effects rather than some of them having LESS (or fewer) side effects. So, the choice should be based on how you do on a medicine and what side effects are important to you.

Clozapine is really the only antipsychotic that has been shown to be better than the others. However, it has lots of side effects (and one rare but potentially nasty one that means people taking it have to have regular blood tests) so isn’t used unless at least two other antipsychotics have been tried and haven't worked.

Sometimes the symptoms of psychosis can become very severe. This can result in the person becoming very distressed and/or too difficult to cope with and might need to be admitted to hospital. This might then become what is called an "acute psychiatric emergency" or crisis. The treatments for this may need to include some other medicines just to calm the person down and prevent harm to that person, or others. If this happens, follow the link to some information that might help explain what might be going on.

Updated 10.11  

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Download a handy summary chart (PDF format) comparing the main medicines for psychosis e.g. names, how they work, doses, how long they take to work, some side effects, how long to take and how to stop.

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You should think carefully about taking any chemical that affects your body, including your brain. So think carefully before your next cup of tea or coffee!

This is a contraversial area in psychosis and schizophrenia, but it is quite clear that antipsychotic medicines do reduce psychotic symptoms and reduces the chance of them coming back.

For an appeal for everyone to have a sense of balance about medicines and talking therapies please click here for our take on it.

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For a first episode of psychosis, it is not certain exactly how long to keep taking an antipsychotic but at least two years significantly reduces the chances of the symptoms coming back. If someone can find an antipsychotic that doesn't give too many side effects, that is probably quite a good deal. It may also be that the antipsychotics not only prevent schizophrenia getting worse, but if taken early (i.e. so the "Duration of Untreated Psychosis" or DUP is less than a few months) they might even stop it happening at all. The longer someone has psychotic symptoms without treatment, the less chance there is of getting better.

If you have more than one episode, then taking antipsychotics for at least 5 years will reduce your chances of becoming ill again. The choice must be yours. If you are getting side effects, it may be possible and a good idea to reduce your dose a little. The dose that keeps you well may not need to be as high as the dose that got you well.

Data from the large, independent CATIE study (no drug companies involved!) says that if you keep switching medicines, then the response (positive effect) seems to reduce each time. This isn’t saying that you shouldn’t switch but that it would be a good idea to get the best out of one medicine before going to the next one e.g. altering the doses, timing, managing side effects as much as possible. The next medicine isn’t likely to be perfect either.

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Before going onto another medicine, it is worth trying to get the best out of the first one. There is a risk that switching medicines too quickly means you don’t get the best out of one medicine. Then perhaps you start to search for the “magic bullet”, expecting the drugs to work quicker and having less patience. There are of course no “magic bullets”. Most symptoms have started to happen over a few weeks, months or years, not a few days, so it is perhaps unfair to expect them to go over a few days. The symptoms are more likely to go gradually over weeks or months. If side effects are the main problem with a medicine, try to cope with these by e.g. changing times, splitting the dose, manage side effects etc.

The best thing to do is set out your aims of success of any treatment in advance and be realistic. If you decide to stop, then that’s your decision, but make sure you consider the chances of becoming unwell again (and consequences of that to yourself and the people close to you).

First episode:

If someone’s symptoms have not improved after about one or two weeks and the person isn’t getting too many side effects, then usually the dose should be increased. If they are no better at four weeks at a good dose, then usually switching to another antipsychotic is the best plan. If the person is getting side effects they can’t cope with then it may be a good idea to switch to another antipsychotic a bit earlier, or adjust the dose a bit.

Acute psychosis

If someone is suffering from an acute psychosis, most people will start to improve within 1-2 weeks at the latest. If there has been no improvement over 6-8 weeks, then increasing the dose further is unlikely to help. It may take a while to find the right dose, which gives the right balance betweem effect and side effects. If the person hasn't improved at all after 2 weeks this means the medicine is highly likely not to work after 2 weeks (O’Gorman 2011).

Clozapine can only be used for “treatment-resistant schizophrenia” i.e. it has not got better with at least two other antipsychotics taken at the right dose for enough time. If no improvement occurs after 3 weeks at any dose of clozapine, it is unlikely to be any better at that dose, but some studies have shown a gradual improvement accumulating over 6 months or longer.

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There are no easy answers to this and it is a very individual choice. Generally one medicine should always be the aim but combinations (often called “polypharmacy”) sometimes help. It is rarely of any use to combine drugs with similar ways of working. Below are some of the combinations that are used with the reasons. This is not a complete list but you might want to talk to your prescriber about any combinations not on this list you may be prescribed.

Although combinations of antipsychotics have been used quite a lot, the general aim is to get the best out of one antipsychotic e.g. fiddle with the dose and timings to get the best effect with the least side effects. Sometimes adding another antipsychotic to clozapine is tried if clozapine has only been partly effective.

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If you want to read up a bit more on the best treatments, there are many guidelines that you can look at. Probably the most important of these for England and Wales are those produced by NICE (the National Institute for Health and Clinical Excellence). NICE is an independent body that is asked to produce advice about preventing and treating illnesses and promoting good health. Scotland and Northern Ireland have their own similar bodies.

Each set of NICE Guidelines is written by an independent and carefully chosen group of specialists and experts (including service users and carers). They carefully review the available evidence and base their guidelines on this.

There are two main types of NICE guidance:

• "Technology appraisal". These look at an "intervention" (i.e. a medicine, a surgical operation etc) and decide if they think the evidence is good enough to make this intervention a standard and/or if it is cost-effective compared to other treatments

• "Clinical guidelines", which look at a particular condition (e.g. hypertension, lung cancer, depression, Parkinson's disease, bipolar disorder etc) and give guidelines covering medicines, services, support etc.

The guidelines are well intentioned and give generally sound guidance (although these are sometimes controversial). They are, however, only "guidelines", so are not rigid instructions.

When NICE issues a guideline, it produces a full set, and all of these are available on the NICE website:

• Full guideline (very long and detailed, often several hundred pages, for anorak healthcare professionals only)

• Official guideline (usually 10-30 pages, the summary version for healthcare professionals)

• Quick reference guideline for healthcare professionals (usually only a couple of pages)

• User-friendly summary for service users, carers and the general public

These should then be reviewed, usually about 4-5 years or sooner if more information becomes available.

As a general rule, you should start with treatments recommended by NICE as these are the ones with most evidence that they work. However, if these do not help you, it may be useful to try other treatments.

• NICE (there aren's any guidelines for psychosis as such, but click here for the schizophrenia guidelines)

• Scottish Intercollegiate Guidelines Network (SIGN) where there is a guideline on puerperal psychosis (postnatal psychosis) (November 2007)

• Northern Ireland 

There are plenty of other guidelines and so-called "consensus statements" (where a group of experts and specialists pool their ideas, based on their own experiences as well as what the published papers say, rather than just what the published studies say). These will have been produced for healthcare professionals by such bodies as BAP (British Association for Psychopharmacology). 

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The resources below provide more information about psychosis. Please note that this is not an exhaustive list. We welcome your feedback on resources that you think should be listed here.

Mental Health Ireland has a great links page on this extensive site

Your Mental Health Ireland, with a young person’s page as well

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