29th January 2024

Assessment

It is important to establish the cause of psychosis, its onset, duration, and its effect on the individual’s personal functioning. This is best done via a comprehensive psychiatric assessment. Each domain should be assessed independently (positive symptoms, negative symptoms, cognition, mood and anxiety symptoms), noting severity, duration and impact on social functioning. Due to the nature of Schizophrenia, it may be difficult to obtain a coherent history from the individual themselves; therefore, it is important to take a collateral history from family, a friend or care worker. It is advisable to ensure that you are wearing an alarm pendant, chaperoned, and in clear line of an exit, as patient agitation can escalate rapidly. Within the assessment, it is particularly important to pay attention to areas such as history of substance misuse, family history of any mood or psychotic disorders and psychosocial history to identify any risk factors. A thorough risk assessment that includes an assessment of suicide risk, as rates of suicide in schizophrenic patients can be as high as 10%.

Investigations

Prior to initiating treatment with antipsychotics, a thorough physical health assessment must be conducted. This includes:

• Baseline bloods (FBC, U+E, LFT, CRP), including lipids and HBA1C (due to increased risk of metabolic syndrome with antipsychotic use), Thyroid Function Test (risk of hypothyroidism), Prolactin (risk of hyperprolactinaemia), and Vit B12, Folate and Ferritin (patients may present in malnourished states)
• ECG: Certain antipsychotics (e.g. Haloperidol) have a higher propensity for prolonging QTc interval or may induce ECG changes, thus obtaining a baseline to compare is essential
• Pregnancy test: certain antipsychotics are teratogenic
• Height, Weight, BMI: Patients taking antipsychotics have increased risk of metabolic syndrome
• General physical examination
• Vital Signs: This is of particular importance when patients are newly commenced on antipsychotics that have a high risk of neuroleptic malignant syndrome (e.g. Haloperidol, Chlorpromazine)
• Urinalysis, including drug screening: can help in ruling out other causes of disordered behaviour, e.g. UTI, cocaine