Who / when
- Adults with marked change in behaviour, hearing voices or seeing things, fixed false beliefs not shared by their culture, agitation or withdrawal, or neglect of self and responsibilities.
- Adolescents, pregnant or breastfeeding women and older adults: see special groups in Treat, and consult a specialist.
Red flags: refer now
- Delirium or a medical cause: fever, confusion that comes and goes, head injury, low glucose, infection (including cerebral malaria), dehydration, or recent medicines such as steroids or some antimalarials.
- Imminent risk of suicide or of harming others.
- Severe agitation or aggression.
- Fever, rigid muscles and high BP on an antipsychotic (possible neuroleptic malignant syndrome).
Look for a physical cause firstCheck glucose (give glucose if low), vital signs, temperature and oxygen saturation. Treat the physical cause and refer as needed before diagnosing psychosis.
Assess
- Rule out delirium and physical causes (see Red flags). Also consider dementia, depression, alcohol or drug intoxication or withdrawal.
- Psychosis: at least two of: delusions; hallucinations; disorganised speech or behaviour (including self-neglect).
- Mania: several of the following together for at least 1 week, enough to disrupt life: raised or irritable mood; little need for sleep; overactivity, fast speech; loss of inhibitions; reckless behaviour; distractibility; inflated self-esteem.
- Ask about suicide risk, alcohol and drugs, previous episodes and treatment.
- Weight, BP and, if possible, glucose and lipids before starting medicine.
Classify
| Picture | Classify as | Action |
|---|
| Confusion, fever, abnormal vital signs, low glucose | Possible delirium or medical cause | Treat the cause; refer |
| Severe agitation or aggression | Agitation | Safety first; see Treat |
| Mania criteria met | Bipolar disorder, manic episode | Stop antidepressants; mood stabiliser or antipsychotic |
| Two or more psychotic symptoms | Psychosis | Start an antipsychotic |
Treat
Antipsychotics (one at a time; start low, go slow)
Give an effective dose for at least 4 to 6 weeks before judging it ineffective. The 2023 update also lists aripiprazole, olanzapine, paliperidone and quetiapine; dose per national formulary.| Medicine | Adult dose (mhGAP-IG) |
|---|
| Haloperidol | 1.5 to 3 mg daily; increase as needed (maximum 20 mg a day) |
| Risperidone | 1 mg daily; increase to 2 to 6 mg (maximum 10 mg) |
| Chlorpromazine | 25 to 50 mg daily; increase to 75 to 300 mg |
| Fluphenazine depot | 12.5 mg IM, then 12.5 to 50 mg every 2 to 4 weeks (not in pregnancy or breastfeeding) |
- Side effects: stiffness, tremor, restlessness or acute dystonia (reduce the dose; short-term biperiden or trihexyphenidyl if severe); weight gain and raised glucose and lipids; QT prolongation.
- Mania: stop any antidepressant. Start a mood stabiliser (lithium only with laboratory monitoring and specialist supervision; otherwise valproate or carbamazepine) or an antipsychotic. A short course of diazepam (2 to 4 weeks at most) can help agitation.
- Valproate must not be used in women and girls who could become pregnant. In pregnancy avoid valproate, lithium and carbamazepine; low-dose haloperidol with specialist advice.
Agitation or aggression
- Safety first. Stay calm, listen, do not argue back, involve carers and staff; remove triggers.
- Agitation from psychosis or mania: haloperidol 2 mg by mouth or IM every hour, up to 5 doses (maximum 10 mg). Extreme violence: haloperidol 5 mg IM, repeat after 15 to 30 minutes if needed (maximum 15 mg). Treat dystonia with biperiden.
- Agitation from alcohol or sedative withdrawal: diazepam (see the alcohol protocol).
Follow-up
- As often as possible, even daily, until acute symptoms respond; then monthly to every 3 months.
- Each visit: symptoms, adherence, side effects, weight, BP, glucose; alcohol and drugs; stressors.
- Poor adherence: discuss reasons; consider a depot injection.
- First episode: continue medicine for at least 12 months after symptoms resolve (WHO 2023: at least 7 to 12 months in remission), then reduce slowly with specialist advice.
- Bipolar disorder: maintenance for at least 2 years after the last episode.
Counsel
- The symptoms are due to a treatable health condition; recovery is possible. No one is to blame.
- Take the medicine regularly and come back for every review; relapse is common, so learn the early signs.
- Avoid alcohol, cannabis and other drugs; keep regular sleep and routine.
- Carers: do not argue about the beliefs; be calm and supportive; avoid criticism and hostility; avoid restraining the person, while keeping everyone safe.
- Return to work, school and social activities as soon as possible; long hospital stays should be avoided.
Your family member has an illness of the mind that can be treated. The medicine helps the voices and fears settle. Please be patient and kind, and bring them back to the clinic every time.
When to refer
- Same day: suspected delirium or physical cause you cannot treat; severe aggression not settling; imminent suicide risk.
- Not improving after two antipsychotics at adequate dose and duration (for clozapine under a specialist).
- Lithium treatment without laboratory monitoring.
- Pregnancy, breastfeeding, adolescents and older adults.
Sources
World Health Organization. mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings, version 2.0. 2016. World Health Organization. Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders. 2023. World Health Organization. WHO Model List of Essential Medicines. 2025.