Article: Skikic M, Arriola JA. First Episode Psychosis Medical Workup: Evidence-Informed Recommendations and Introduction to a Clinically Guided Approach. Child Adolesc Psychiatr Clin N Am. 2020;29(1):15-28. doi:10.1016/j.chc.2019.08.010
Fellow: Ashleigh Slemmer, DO, MBA; Nationwide Children’s Hospital in Columbus, Ohio
Summary: New onset psychosis in the pediatric population is likely more prevalent than most assume – upwards of 17% in those 9-13 years of age and 8% in 14-17 year olds experience psychotic symptoms (Kelleher et al., 2012). Currently, there are no standardized guidelines for the workup and initial management of these patients. This review article summarizes the data on diagnostics to evaluate for secondary causes of psychosis in patients presenting with their first episode of psychosis with assigned recommendations based on the Strength of Recommendation Taxonomy guidelines (SORT). Overall, the authors recommend a tiered approach, with basic screenings labs for all patients and a history- and exam-guided approach for second tier testing.
Key Strengths: The article offers a nice review of the literature, functions as a way to recognize potential gaps for future studies, and provides a stepping stone for a systematic review. The use of the SORT and level of data score provides some information on data quality of the individual studies.
Limitations/Flaws: One of the larger limitations of the article is the lack of a methodological description, so it is unclear if the recommendations are based on a subset of the literature or is all inclusive and whether a valid risk of bias tool was utilized.
Takeaway Message: There is a considerable need for more, higher quality research on new onset psychosis in the pediatric population. There are drastic differences in practices with regards to the diagnostic workup for these patients, which has resulted in significant variability in care and therefore higher costs. This article provides a stepwise approach to the evaluation of secondary causes of psychosis based on evidence. It may assist in the creation of a clinical practice guideline for the initial screening of these patients which would allow for some standardization and, subsequently, future research on outcomes.
Practice Impact: When managing a patient with first episode psychosis, the 1A recommendations for initial screening tests include a toxicology screen (diagnosis), folate level (prevention and diagnosis), and 25-OH Vitamin D level (prevention and morbidity). The initial workup should not include neuroimaging (head CT or brain MRI unless clinically indicated.
Reference: Kelleher I, Connor D, Clarke MC, Devlin N, Harley M, Cannon M. Prevalence of psychotic symptoms in childhood and adolescence: a systematic review and meta-analysis of population-based studies. Psychol Med. 2012;42(9):1857-1863. doi:10.1017/S0033291711002960
Fellow: Ashleigh Slemmer, DO, MBA; Nationwide Children’s Hospital in Columbus, Ohio
Summary: New onset psychosis in the pediatric population is likely more prevalent than most assume – upwards of 17% in those 9-13 years of age and 8% in 14-17 year olds experience psychotic symptoms (Kelleher et al., 2012). Currently, there are no standardized guidelines for the workup and initial management of these patients. This review article summarizes the data on diagnostics to evaluate for secondary causes of psychosis in patients presenting with their first episode of psychosis with assigned recommendations based on the Strength of Recommendation Taxonomy guidelines (SORT). Overall, the authors recommend a tiered approach, with basic screenings labs for all patients and a history- and exam-guided approach for second tier testing.
Key Strengths: The article offers a nice review of the literature, functions as a way to recognize potential gaps for future studies, and provides a stepping stone for a systematic review. The use of the SORT and level of data score provides some information on data quality of the individual studies.
Limitations/Flaws: One of the larger limitations of the article is the lack of a methodological description, so it is unclear if the recommendations are based on a subset of the literature or is all inclusive and whether a valid risk of bias tool was utilized.
Takeaway Message: There is a considerable need for more, higher quality research on new onset psychosis in the pediatric population. There are drastic differences in practices with regards to the diagnostic workup for these patients, which has resulted in significant variability in care and therefore higher costs. This article provides a stepwise approach to the evaluation of secondary causes of psychosis based on evidence. It may assist in the creation of a clinical practice guideline for the initial screening of these patients which would allow for some standardization and, subsequently, future research on outcomes.
Practice Impact: When managing a patient with first episode psychosis, the 1A recommendations for initial screening tests include a toxicology screen (diagnosis), folate level (prevention and diagnosis), and 25-OH Vitamin D level (prevention and morbidity). The initial workup should not include neuroimaging (head CT or brain MRI unless clinically indicated.
Reference: Kelleher I, Connor D, Clarke MC, Devlin N, Harley M, Cannon M. Prevalence of psychotic symptoms in childhood and adolescence: a systematic review and meta-analysis of population-based studies. Psychol Med. 2012;42(9):1857-1863. doi:10.1017/S0033291711002960