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Case
The patient is illustrative. Jordan, 20, a college student, is brought to the clinic by their parents. Over 4 months Jordan has withdrawn from friends, stopped attending classes and started saying that neighbors are recording them through the walls. Jordan hears voices commenting on their actions and has been sleeping only a few hours a night. They use cannabis several times a week. There is no history of head injury or seizures. An uncle has schizophrenia.
The comprehensive assessment
Psychiatric history and mental status examination. Jordan is guarded with poor eye contact. Speech is soft and sometimes tangential. Thought content includes persecutory delusions. They describe auditory hallucinations, and their affect is flat. They deny suicidal or homicidal thoughts, but say they "might have to do something" if the recording continues, which needs careful exploration. Insight is poor.
Ruling out other causes. Psychosis can have medical and substance-related causes, so the evaluation includes:
| Area | Assessment |
|---|---|
| Substances | Urine drug screen; detailed history of cannabis potency and frequency, and other substances |
| Medical | Physical exam, complete blood count, metabolic panel, thyroid function, and other tests guided by history, such as HIV or syphilis testing; neuroimaging if there are neurological signs |
| Mood | Screening for mania or depression with psychotic features, since treatment differs |
| Safety | A structured suicide and violence risk assessment, including access to firearms |
Measurement. Using a quantitative rating of symptoms at baseline lets the clinician track response.
Baseline monitoring before antipsychotics. Weight, BMI, waist circumference, blood pressure, fasting glucose or HbA1c and lipids, because many antipsychotics cause metabolic side effects.
Working diagnosis
Psychotic symptoms for 4 months with functional decline are consistent with schizophreniform disorder, with schizophrenia possible if they continue beyond 6 months. A cannabis-induced psychotic disorder remains in the differential and will be reassessed.
Treatment plan based on the APA guideline
The American Psychiatric Association practice guideline for schizophrenia (Keepers et al., 2020) includes recommendations that apply to Jordan:
- Treat with an antipsychotic medication and monitor for effectiveness and side effects.
- Offer care in a coordinated specialty care program for patients experiencing a first episode of psychosis. These team-based programs combine medication management, psychotherapy, family education and support, case management, and supported employment and education.
- Provide cognitive behavioral therapy for psychosis and psychoeducation.
- Offer supported employment services, which here means supported education to help Jordan return to college.
- Use clozapine if symptoms do not respond to adequate trials of other antipsychotics, or if suicide risk remains substantial despite other treatments.
Next steps for Jordan
- Discuss starting a second-generation antipsychotic at a low dose, choosing one with lower metabolic risk, and check how Jordan feels about taking medication.
- Refer to the nearest coordinated specialty care program.
- Provide motivational interviewing around cannabis use, explaining its link with worsening psychosis.
- Develop a safety plan with Jordan and their family, and remove access to firearms.
- See Jordan weekly at first, with metabolic monitoring repeated as recommended.
References
Keepers, G. A., Fochtmann, L. J., Anzia, J. M., Benjamin, S., Lyness, J. M., Mojtabai, R., Servis, M., Walaszek, A., Buckley, P., Lenzenweger, M. F., Young, A. S., Degenhardt, A., & Hong, S.-H. (2020). The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. American Journal of Psychiatry, 177(9), 868–872. https://doi.org/10.1176/appi.ajp.2020.177901
