What is the initial approach for a 17-year-old patient presenting with semi-psychotic (psychotic-like) symptoms?

From the Guidelines

The initial approach for a 17-year-old patient presenting with semi-psychotic symptoms should be a comprehensive assessment to ensure safety and determine the appropriate level of care, as recommended by the American Psychiatric Association 1. This assessment should include evaluating immediate safety risks, such as suicidal or homicidal ideation, and establishing whether hospitalization is necessary. A thorough psychiatric evaluation is crucial, including a mental status examination, medical history, substance use screening, and collateral information from family members.

Key Components of the Assessment

• Evaluate the reason for presentation, patient's goals and preferences for treatment, and review of psychiatric symptoms and trauma history 1
• Assess tobacco use and other substance use, psychiatric treatment history, and physical health 1
• Perform a mental status examination, including cognitive assessment, and assess the risk of suicide and aggressive behaviors 1
• Order baseline laboratory tests, including complete blood count, comprehensive metabolic panel, thyroid function tests, toxicology screen, and consider neuroimaging if organic causes are suspected

Treatment Approach

Since the patient is a minor, it is essential to involve parents or guardians in the assessment and treatment planning process while maintaining appropriate confidentiality. Consultation with a child and adolescent psychiatrist is strongly recommended.

Medication Considerations

Antipsychotic medication should only be initiated after careful assessment, typically starting with low doses of second-generation antipsychotics such as risperidone (0.5-1mg daily) or aripiprazole (2-5mg daily), with close monitoring for side effects which adolescents may be particularly sensitive to. Avoid rushing to diagnose a specific psychotic disorder, as adolescent-onset psychosis can represent various conditions, including schizophrenia, bipolar disorder, major depression with psychotic features, substance-induced psychosis, or medical conditions. The American Psychiatric Association recommends a comprehensive, person-centered treatment plan that includes evidence-based nonpharmacological and pharmacological treatments 1.

From the FDA Drug Label

The efficacy of oral olanzapine in the acute treatment of schizophrenia in adolescents (ages 13 to 17 years) was established in a 6-week double-blind, placebo-controlled, randomized trial of inpatients and outpatients with schizophrenia (n=107) who met diagnostic criteria according to DSM-IV-TR and confirmed by the Kiddie Schedule for Affective Disorders and Schizophrenia for School Aged Children-Present and Lifetime Version (K-SADS-PL).

The initial approach for a 17-year-old patient presenting with semi-psychotic (psychotic-like) symptoms is to assess and diagnose the patient according to DSM-IV-TR criteria and consider using the Kiddie Schedule for Affective Disorders and Schizophrenia for School Aged Children-Present and Lifetime Version (K-SADS-PL) for confirmation.

• The patient may be a candidate for oral olanzapine as part of the treatment plan, with a flexible dose of 2.5 to 20 mg/day, as supported by the statistically significant reduction in BPRS-C total score in clinical trials 2.
• It is generally recommended that responding patients be continued beyond the acute response, but at the lowest dose needed to maintain remission.
• Patients should be periodically reassessed to determine the need for maintenance treatment 2.

From the Research

Initial Approach for Semi-Psychotic Symptoms

The initial approach for a 17-year-old patient presenting with semi-psychotic (psychotic-like) symptoms involves a thorough evaluation and diagnosis.

• The patient's history, mental state, and collateral history should be examined to identify the underlying cause of the symptoms 3.
• The diagnosis of psychosis is a diagnosis of exclusion, and delirium and dementia should be ruled out 4.
• A distinction should be made between bipolar disorder, schizophrenia, and other causes of psychosis 3.

Help-Seeking and Health-System Delays

• Delays in receiving effective treatment for psychosis can have adverse consequences, and help-seeking delays and health-system delays should be minimized 5.
• Families play a vital role in hastening receipt of effective treatment, and their involvement in help-seeking can reduce delays 5.
• The patient's premorbid adjustment, family history of mental illness, and negative symptoms can affect help-seeking behavior and delays 5.

Treatment and Management

• The treatment of psychosis depends on the underlying cause and may involve antipsychotic medication, mood stabilizers, or other therapies 6, 4.
• Early intervention services can provide effective treatment and support for patients with first-episode psychosis 3, 5.
• Mental health first aid guidelines can provide a general set of strategies for providing initial assistance to a person experiencing psychosis 7.