Biomedical Investigations

It is necessary to conduct a careful physical and mental state examination in a young person with a first episode of psychosis as a first step in excluding other medical conditions that could contribute to the symptoms [42]. Such conditions include head injury, temporal lobe epilepsy, infection or malignancy of the central nervous system, and some endocrine and metabolic disorders.

Only a small percentage of young patients with a first episode of psychosis are found to have an organic cause for their illness. Often this can be detected from clinical examination, so routine laboratory or radiological investigations in otherwise healthy young people rarely detect significant abnormalities - i.e. the yield is low. However, if systematic investigations

Table 2.10 Recommended and optional investigations in first-episode psychosis [42]

Recommended before commencing antipsychotic medication

• Urine tests: drug screen, urine microscopy

• Full blood examination, erythrocyte sedimentation rate

• Renal function tests (electrolytes, urea, creatinine)

• Serum calcium and phosphate

• Liver function tests

Thyroid function tests

• Fasting glucose

• Electrocardiogram

As early as possible

• Computed tomography brain scan or, ideally, magnetic resonance imaging

• Neurocognitive assessment

Optional, depending on clinical indications

• Electroencephalogram

• Urine tests: pregnancy test, urinary porphyrins

• Blood tests: pregnancy test, nutritional indices (e.g. vitamin B12, folate, iron); autoantibody screens, hepatitis screens, HIV and syphilis screens, copper studies

• Echocardiogram are not carried out at this stage, it is unlikely they will be conducted in the future. A physical examination and laboratory investigations can also assess the effect of the psychosis and its treatment on general health.

In the early phase of psychosis, young people with little or no experience of medical procedures can be anxious and suspicious of physical examinations and investigations. Reassurance and careful explanations of the procedures and the results are essential.

Measuring vital signs and a brief neurological examination are useful as part of the first community-based assessment, followed by a more complete physical examination in a clinic or hospital, if appropriate, when laboratory investigations are being carried out.

Recommended and optional investigations are listed in Table 2.10. By far the most useful investigation is a urine drug screen. Substance use is common in this group of patients, and regular screening will establish the role of drug abuse in the presentation or perpetuation of psychosis. Tests to assess other general medical needs of patients should be considered, depending on factors such as their age, exposure to physical risks and findings on physical examination.

A computed tomography (CT) brain scan is recommended, but it is usually preferable to wait until the psychosis has settled, so patients can tolerate and cooperate with the procedure. Urgent CT and magnetic resonance imaging

(MRI) scans are recommended only when there is a strong indication of an organic cause for the psychosis. The clinical significance of abnormalities found on CT and MRI scans in first-episode patients is often unclear [50].

The value of a routine electroencephalogram (EEG) is questionable. However, EEGs should be used if there is a history of epilepsy, birth trauma, head injury, mental handicap or significant findings on CT or MRI.

Psychosis is typically associated with a range of neuropsychological deficits, particularly in attention, information processing, verbal memory and learning. These deficits are apparent even during the first episode. Neuropsychological testing may be useful in determining the prognosis and in guiding approaches to psychological and social interventions. However, accurate neuropsycholo-gical testing is usually difficult while a patient is experiencing acute psychotic symptoms and it is unlikely to assist in making a diagnosis.

Review of cardiac function, including an electrocardiogram, is now indicated in patients who are being considered for antipsychotic medications, particularly clozapine, which are known to have adverse cardiovascular side effects. The findings may influence the choice of medication. Other examinations may be necessary depending on the particular medication that is being considered [11].

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