GP Guidance on Early Detection
Emerging psychosis and young people: what you need to know.
Why is this important for GPs?
Psychosis is one of the most serious conditions that can affect a young person:
- Suicide – 10% lifetime risk; usually within first 5 yrs; highest risk at 1st relapse
- 12% end up with no job – a path to social exclusion
Its first appearance can be bewildering for an individual. As GPs we are often the first point of contact with a health professional.
There is overwhelming evidence for the benefits of intervening early in the illness:
- Suicide risk is halved
- Over 50% will secure a job
- If caught very early, it is possible to delay or, better, prevent the onset of a disabling psychotic illness.
Who is at Risk?
Psychosis is about as common as insulin dependent diabetes.
Previously we relied on family history to alert us to risk. Yet only a small proportion of those with psychosis have an immediate family member with psychosis.
But we now know:
- The life time risk of psychosis is 3 in 100
- It usually starts when young:
- 80% aged between 16 – 30
- 5% are aged 15 or less
- It is about 3 times more common for those living in inner city areas
- Prolonged Cannabis use increases the risk of developing psychosis
Awareness of those at most risk combined with sensitivity to the earliest symptoms can allow us to predict individuals with 30 - 40% chance of developing psychosis.
Presenting Features of Emerging Psychosis
Emerging psychosis tends not to present in ‘neat parcels’. Many GPs suspect that something is ‘not quite right’ prior to the emergence of clear psychosis.
Early symptoms which are often difficult to define or indeed uncover may include:
- poor sleep, panic, mood changes
- social withdrawal, isolation, loss of job, broken relationships.
- early psychotic thinking such as suspicion, mistrust or perceptual changes.
If uncertain, do not simply dismiss change as adolescence or due to substance misuse. Be prepared to keep a watching brief. Follow up a missed appointment. Take family concerns seriously; they can often provide important clues.
Key learning point: Psychosis is usually heralded by a gradual deterioration in intellectual and social functioning
GP recognition of early changes, clinical intuition and acting on family concerns are the key to early detection.
Ask yourself: “Would I be surprised if this turned out to be psychosis within the next 6 months?”
What should I do?
If you suspect the possibility of an emerging psychosis then it is important to act promptly.
Consider and check out for physical illness e.g.
- Drug / substance intoxication (a frequent co-morbidity in first episode psychosis)
- Drug withdrawal states
- Liver function disorders
- Systemic infections
- Nutritional deficiencies
- CNS abnormalities
- Metabolic disorders
Seek specific evidence of psychotic thinking. The sort of questions could include:
Have you felt that something odd might be going on that you cannot explain?
Have you been feeling that people are talking about you, watching you or giving you a hard time for no reason?
Have you been feeling, seeing or hearing things that others cannot?
Have you felt especially important in some way, or that you have powers that let you do things which other cannot?
What should happen?
The presence of any of these symptoms in a distressed young person should lead you to seek specialist advice and assessment for potential psychosis.
Assess for risk, given the frequency of self harm in this early phase (less commonly harm to others). Evidence of such risk demands urgent action.
Prompt assessment by services specialised in Early Intervention in Psychosis [1] should ensure these young people and families get the right help at the right time.
Remember:
EARLY DETECTION SAVES LIVES
YOU CAN MAKE A DIFFERENCE
Footnotes
[1] In England all Primary Care Trusts are required to commission appropriate Early Intervention in Psychosis Services.