From the Research
A primary care physician managing a patient with delusions should first ensure patient safety, then conduct a thorough evaluation to identify the underlying cause, as suggested by the most recent and highest quality study 1. To determine if someone is delusional, a primary care physician (PCP) should perform a mental status examination, which includes assessing the patient's appearance, behavior, speech, mood, thought process, and thought content, as outlined in a study from 2009 2. Key components of the evaluation include:
- A complete physical examination
- Relevant laboratory tests, such as CBC, metabolic panel, thyroid function, B12, folate, urinalysis, and toxicology screen
- Consideration of neuroimaging if indicated
- A thorough medical and psychiatric history While arranging a psychiatric referral, the PCP may initiate low-dose antipsychotic medication, such as risperidone (0.5-1mg daily) or olanzapine (2.5-5mg daily), monitoring closely for side effects, as supported by a study from 2020 1. Establishing a therapeutic alliance is crucial, as is involving family members with the patient's consent, and the PCP should avoid directly challenging delusions but instead acknowledge the patient's distress while offering alternative explanations, as suggested by a study from 2015 3. Regular follow-up appointments should be scheduled every 1-2 weeks initially to monitor symptoms and medication effects, and if the patient presents with suicidal or homicidal ideation or severe functional impairment, immediate psychiatric hospitalization may be necessary. This approach addresses the immediate needs while working toward comprehensive psychiatric care, recognizing that delusions often stem from conditions like schizophrenia, bipolar disorder, severe depression, or medical causes that require specialized treatment, as noted in a study from 1989 4.