What Investigations Are Ordered in Patients with First-episode Psychosis?

Abstract

Psychiatrists are often left with the dilemma of which investigations to order in adolescents presenting with a first episode of psychosis. Blood work, urine studies, and neuroimaging studies were tracked in 13 adolescents admitted with a diagnosis of first-episode psychosis over a 13-month period to the Children’s Hospital of Eastern Ontario. Variation was found in the amount of investigation ordered: 85% of patients received a drug screen; 54% a CT scan; 8% an MRI; 92% a CBC with differential; 92% electrolytes. Abnormalities of CT scans were detected in 2 patients (29%); in neither case did the result lead to a diagnosis of brain-lesion-related psychosis, nor did it affect the clinical care of the patient. This study highlights the need to develop clinical practice-guidelines for the workup of first-episode psychosis in adolescents. First-episode psychosis has received considerable attention in both the pediatric and adult literature. One area of ongoing research is the degree to which children and adolescents require investigations to rule in or rule out non-psychiatric disease. According to the Diagnostic and Statistical Manual of Mental Disorders 4 Edition Text Revision (DSM-IV-TR), the diagnosis of schizophrenia and other psychotic illnesses require that criteria be met: where “the disturbance is not due to the direct physiological effects of a substance (e.g., of abuse or a medication) or a general medical condition”(1). Yet, in spite of these essential criteria, a standardized workup for first episode psychosis in children and youth is difficult to find. Psychiatry associations and textbooks differ in their recommendations and often leave the decision to perform a test at the discretion of the attending physician. A summary of different guidelines can be found in Table 1.