In practice, GPs rarely make a diagnosis of psychosis in isolation from specialist services. GPs have a role in eliciting and recognising early clinical features of psychotic disorders, deciding on the need to refer to specialist service or clinician (e.g. CAMHS, or early psychosis services), and subsequently to be involved in follow-up of the patient’s management, support and psychoeducation for family and friends, monitoring of engagement with services, treatment and metabolic screening.
Screening should be considered a stepwise process (see page 40 of the Australian Guidelines):
- Is the young person experiencing psychosocial difficulties?
- If yes, could these be attributed to a specific mental disorder (depression, anxiety or substance use?)
- If symptoms of depression, anxiety or substance use are present, is there a possibility that such symptoms are part of a psychotic disorder?
- Possible screening questions for psychosis include:
- Thought disorder – “Have you noticed a change in the way that you think – slower, faster, more confused?”
- Delusions – “Does anything unusual seem to be happening, or have you thought that strange things were happening around you, or to you??”
- Paranoia – “Have you been worried that something bad might happen to you, or that people have turned against you in some way?”
- Hallucinations – “Have you noticed any new and unusual experiences – like hearing things or seeing things that others could not or when other people are not present?” Also check for other possible sensory hallucinations.
- Where psychotic symptoms are present, their duration, frequency, intensity, associated distress and the relationship between them and other symptoms such as mood should be determined.
- Assess risk to self and others including specifically obtaining information about the nature of command hallucinations as part of a risk assessment. For example, do they instruct them to act in certain ways? Or is the content/tone of the hallucinations derogatory?
- If not referring to a specialist, consider a complete medical work up for first-episode psychosis (see page 40 of the Australian Guidelines)
Cultural aspects should be taken into account when assessing for psychosis. For example, for some Aboriginal and Torres Strait Islander people and some other backgrounds, visitation by, and hearing voices of deceased loved ones are normal and sometimes even desired experiences, and should not necessarily be suggestive of psychotic symptoms. If unsure, ask the young person about how they regard these voices, or consider consulting with a cultural advisor.
Treatment is not generally initiated by the GP, but can be after a secondary consultation if the young person’s symptoms are not severe enough to require admission, risk is low, and/or the GP is in a rural or remote setting without access to specialist teams that can provide diagnosis.
- The priority for a GP when working with a young person experiencing psychotic symptoms is to engage the young person, assess risk, and manage the acute symptoms and refer appropriately.
- Assess for substance use issues including the need for medical management of withdrawal and consider specialist services for AOD treatment
- In cases with substance use, consider using motivational interviewing
- Regularly review risk to self and others
Discuss potential physical side effects of medication
Potential physical side effects (including metabolic side effects, weight gain, extrapyramidal motor symptoms, and sexual side effects) should be noted and discussed with people prior to their commencing pharmacotherapy. Such effects should be monitored, managed and addressed early, with a prevention model if possible (e.g., weight management strategies implemented prior to treatment initiation)
Structured behavioural lifestyle interventions should be implemented to improve physical health outcomes for people with early psychosis.
Consider early referral to a dietician and exercise physiologist to assist prevention of metabolic consequences of treatment.
Tobacco cessation should be offered routinely to young people with early psychosis.
- If considering medication, seek psychiatric referral or supervision.
- It is really important to be cautious in prescribing antipsychotics to young people and to weigh up the benefits and side effects of antipsychotic medication
- Atypical antipsychotics are usually prescribed rather than traditional antipsychotics due to their lower incidence of extrapyramidal side effects.
- Start low and go slow.
- Look at differential diagnoses
- The metabolic side effects of anti-psychotic medication can be pronounced and can affect treatment adherence – side effects should be discussed early.
- Patients with first episode psychosis are more vulnerable to experiencing adverse effects.
- Recommended medications are (p56 of the Australian Guidelines):
Note: The use of olanzapine is no longer recommended due to significant metabolic changes occurring within hours or days of starting treatment.
* Substance use can precipitate psychosis, although there may be limited benefit in identifying the presentation as a ‘drug induced psychosis’ approach and treatment remains as above start low go slow, for complex presentations seek special advice re diagnosis.
- Risk to self and others should be determined at each engagement.
- Apply strategies to encourage treatment adherence:
- The therapeutic relationship is key to adherence
- Provide psychoeducation to encourage insight in the patient and their supports
- Be open and honest and discuss difficulties with adherence and side effects
- If a young person is determined not to adhere with their recommended treatment – shift temporarily from optimal care to harm minimisation
- Engagement of family as part of treatment team should be standard
- Identify and determine risk of relapse and act accordingly
- Consider early referral to a dietitian and exercise physiologist to assist prevention of metabolic consequences of treatment
- Metabolic monitoring and other side effects of medication (p77 Australian guidelines)
- Routine metabolic screening should guide intervention, and prevention of physical ill-health must be prioritised as part of routine early psychosis treatment (see Adolescent Cardio-metabolic Protocol)
- Cardiometabolic screening should occur on entry into service, after medication changes, repeated at 1-month and monitored at least every 3 months. Initial screening points should be repeated after any medication changes.
- Every month for the first 3 months, and every 3 months subsequently, measure and record:
- Weight and abdominal circumference
- Total cholesterol and triglyceride levels
- Blood glucose
- White cell and neutrophil counts
- Liver function
- Urea electrolytes
- Prolactin levels
- At baseline, 3 months, and yearly after, check for extrapyramidal side-effects:
- Oral health assessment should form a part of routine assessment using standard checklists that can be completed by non-dental personnel.
Useful resources to assist monitoring:
National Prescribing Service. Antipsychotic monitoring tool
Government of South Australia. Women’s and Children’s Hospital. WCHN Antipsychotic Physical Health and Adverse Effect Monitoring Package
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