First-episode psychosis

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Target exams

Red flags

• New psychosis with fever, fluctuating attention, seizure, dysautonomia or rapid cognitive decline — exclude delirium, encephalitis and other organic causes before locking a primary FEP label
• First psychotic presentation after age 40, or focal neurology — intensified organic work-up including neuroimaging and directed special tests
• Active suicidal intent, command hallucinations to harm, or high violence risk — same-day senior review, means restriction, documented safety plan; do not discharge to an empty plan
• Catatonia, NMS features, or severe agitation with medical compromise — treat as medical-psychiatric emergency
• Persistent high-THC cannabis or methamphetamine use with ongoing psychosis — dual-diagnosis plan; do not withhold treatment for mythical perfect abstinence
• Two adequate adherent antipsychotic failures — do not cycle endless non-clozapine trials; escalate toward treatment-resistance pathway