Early-onset psychosis and mania — formative SAQs

SAQ 1 (10 marks)

A 15-year-old boy is brought to the emergency department after telling his mother that classmates have implanted a chip in his head. He has not slept for four nights, is guarded and frightened, and describes a voice telling him to run. His mother thinks it is "just cannabis and stress." He has smoked high-potency cannabis daily for six months. There is no fever, no fluctuating consciousness, no focal neurology and a normal physical examination, but his marks have fallen and he has lost two friendships over three months. ^{[2] [5]}

1. State the immediate priorities in the first hour, including what must be excluded before any psychiatric label is applied. (3) ^[2]
2. Outline the role of cannabis in this presentation and the evidence supporting your advice. (3) ^{[5] [6]}
3. Describe first-line pharmacotherapy and how the TEOSS trial should inform the choice, plus the baseline and follow-up monitoring. (4) ^{[1] [2] [4]}

Model answer — SAQ 1

(1) Immediate priorities and organic exclusion (3). Safety first: assess suicide and self-harm risk with plan, intent and means, and apply means-restriction safety planning the same day; assess for acute behavioural disturbance and catatonia. Then exclude organic disease before any psychiatric label — full physical and neurological examination, full blood count, electrolytes, liver and renal function, thyroid function, inflammatory markers and a urine drug screen, with neuroimaging and an electroencephalogram if onset is acute, consciousness fluctuates, or focal neurology is present. A psychotic young person is a medical patient first and a psychiatric patient second; a collateral history from family and school is mandatory because he is an unreliable sole historian. ^[2]

(2) Cannabis and the evidence (3). Cannabis is a real, modifiable and dose-related risk factor for psychosis, not an aside. Moore's systematic review found cannabis use associated with a clear increase in psychotic outcomes, and Arseneault's longitudinal study showed adolescent cannabis use raised the risk of adult psychosis in a dose-related way, with earlier, more frequent and higher-potency use being worse. In this boy, daily high-potency use may have triggered or worsened the psychotic picture, so ask about potency, frequency and age of first use, counsel reduction, and arrange a period of supported abstinence and reassessment — persistent symptoms after abstinence warrant full assessment and treatment of a primary disorder. ^{[5] [6]}

(3) Pharmacotherapy, TEOSS and monitoring (4). After specialist assessment, first-line treatment for early-onset schizophrenia is an antipsychotic. The TEOSS trial compared second-generation drugs (risperidone, olanzapine) with the first-generation molindone and found efficacy was similar across groups with different side-effect burdens — so there is no clear efficacy advantage of second- over first-generation drugs, and the side-effect profile decides the choice. Risperidone or aripiprazole are common first-line options. Because duration of untreated psychosis drives long-term outcome, prompt specialist referral and early treatment are themselves the intervention. Baseline monitoring: weight, body-mass index, waist circumference, blood pressure, fasting glucose and lipids, prolactin and an electrocardiogram; then review at 4–6 weeks, 12 weeks and six-monthly, with extrapyramidal side effects, sedation and suicide risk assessed at every contact. ^{[1] [4]}