Protocol · WHO mhGAP
Psychosis (mhGAP)
Psychosis brings hallucinations, fixed false beliefs and disorganised speech or behaviour. First look for a physical cause such as infection or low glucose. Then treat with one antipsychotic, involve the family, avoid restraint and long hospital stays, and follow up closely. Mania needs a mood stabiliser or antipsychotic, never an antidepressant.
- Based on WHO mhGAP
- For doctors, clinical officers and nurses
- Reviewed October 2026
1Who / 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.
2Red 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.
3Assess
- 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.
4Classify
| 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 |
5Treat
Antipsychotics (one at a time; start low, go slow)
| 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).
6Follow-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.
7Counsel
- 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.
8When 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.
9Sources
- World Health Organization. mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings, version 2.0. 2016 (ISBN 9789241549790). Psychoses module (PSY 1 to 3), Tables 1 to 5.
- World Health Organization. Mental Health Gap Action Programme (mhGAP) guideline for mental, neurological and substance use disorders. 2023 (ISBN 9789240084278). Recommendations PSY1 to PSY12.
- World Health Organization. WHO Model List of Essential Medicines. 2025.
Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.