Mental Health · Full case

Psychosis & Schizophrenia

NICE CG178 / NG10EIP · DUPRisk & organic causes

Refer early — don't treat aloneSuspected first-episode psychosis should be referred urgently to a community mental health team / Early Intervention in Psychosis (EIP) service. In primary care, do NOT start antipsychotics for a first episode without specialist assessment (unless advised) — refer

DUP mattersA shorter duration of untreated psychosis (DUP) predicts better outcomes — which is why early recognition and urgent referral matter. NICE CG178 says EIP services should be accessible to anyone with a first episode, whatever their age. The NHS England access standard (treatment within 2 weeks for at least 60%) is targeted at people aged 14–65. EIP reduces relapse and admission

Exclude organic & drug causesPsychosis is not always "psychiatric": exclude delirium, substance misuse/withdrawal (cannabis, stimulants, alcohol), prescribed drugs (steroids, dopaminergics), and organic disease (temporal lobe epilepsy, encephalitis, thyroid, B12, SLE, tumour, dementia). New psychosis in the older patient is delirium until proven otherwise

Positive vs negative symptomsPositive: hallucinations (often auditory), delusions, thought disorder, passivity. Negative: blunted affect, apathy, social withdrawal, poverty of speech — often the most disabling and easily mistaken for depression or "drifting"

Risk — to self, from others, to othersAssess suicide/self-harm (markedly raised in psychosis), risk from command hallucinations/delusions, self-neglect, vulnerability/exploitation, and risk to others (less common than feared but must be assessed) — and safeguarding of any dependents

Antipsychotics need monitoringAntipsychotics carry metabolic (weight, glucose, lipids), cardiac (QTc), prolactin and extrapyramidal effects. NICE CG178 recommends baseline + ongoing physical-health monitoring; GPs play a central role. Clozapine (for treatment-resistant schizophrenia) needs mandatory blood monitoring (agranulocytosis)

People with SMI die youngerPeople with severe mental illness die ~15–20 years earlier, largely from cardiovascular disease — proactive annual physical-health checks (BP, weight, lipids, glucose, smoking) and treatment are a core GP responsibility, not an afterthought

Involve family & carersWith consent, involve family/carers — they aid history, support engagement and adherence, and need support themselves. Family intervention and CBT for psychosis are recommended alongside medication (NICE CG178). Watch the Mental Health Act threshold where risk/refusal endangers safety

📋 Clinical Stem — Psychosis & Schizophrenia

A 21-year-old student brought by his worried mother — withdrawn for months, now convinced his housemates are spying on him and hearing voices commenting on him

Daniel Osei, 21, a university student, is brought in by his mother, who is frightened by how he has changed. Over 4–5 months he has become increasingly withdrawn, stopped attending lectures and seeing friends, and neglected his self-care. In the last few weeks he has become convinced his housemates are spying on him and have "bugged" his room, and he hears two voices commenting on what he is doing. He is guarded and suspicious in the consultation, sleeps poorly, and has been smoking high-potency cannabis daily. There is a family history of schizophrenia in an uncle. He has had fleeting thoughts that he might be "better off dead" but denies any plan. He has no fever or confusion and is physically well.

This stem tests the ability to: recognise a first episode of psychosis (positive symptoms — persecutory delusions, third-person auditory hallucinations — on a background of months of negative symptoms/decline), and to assess it sensitively in a guarded patient; to assess RISK thoroughly (suicide/self-harm, command hallucinations, self-neglect, vulnerability, risk to/from others, safeguarding); to exclude organic and drug causes (cannabis, delirium, organic disease) with history, examination and baseline investigations; to refer URGENTLY to the community mental health team / Early Intervention in Psychosis service rather than starting antipsychotics alone in primary care; to engage and support the family with consent; and to understand the longer-term GP roles (physical-health monitoring, relapse prevention). The SCA challenge is building enough rapport with a suspicious young man to assess risk and facilitate referral, while supporting a frightened parent and being honest within the limits of confidentiality.

Scenario A — First-episode psychosis (this stem) Young person, positive + negative symptoms, cannabis use, family history. Risk assessment; exclude organic/drug causes; urgent EIP/CMHT referral; engage family (consent); don't start antipsychotics alone; safety-net.

Scenario B — Acute risk / crisis Command hallucinations to harm self/others, active suicidality, severe self-neglect, or refusal endangering safety. Crisis team / urgent psychiatric assessment; consider Mental Health Act.

Scenario C — Organic psychosis / delirium Older patient, acute onset, fluctuating, clouded consciousness, fever, focal signs. Treat as delirium — find and treat the cause; admit/medical work-up, not a psychiatric label.

Scenario D — Drug-induced psychosis Stimulants/cannabis/withdrawal. Manage substance use; may resolve, but new psychosis still warrants assessment; comorbid SMI common.

Scenario E — Established schizophrenia (GP role) Known patient on antipsychotics: physical-health monitoring, relapse signs, adherence, clozapine bloods, comorbidity, carer support, shared-care.

Key variables to adapt for First episode vs established vs crisis; positive/negative symptoms; organic/drug causes (age, onset, confusion); risk (self/others/neglect/vulnerability/safeguarding); cannabis/substances; family history & involvement; antipsychotic monitoring & physical health; Mental Health Act threshold; confidentiality with families.

Steps:

Step 1

History — Engage the Guarded Patient · Symptoms · Risk · Organic/Drug Causes · ICE

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The history has to do several hard things at once: build enough trust with a suspicious young man to explore his experiences; characterise the psychotic symptoms (positive and the often-missed negative); conduct a thorough risk assessment; and screen for the organic and drug causes that must not be mislabelled as schizophrenia. Rapport is not a nicety here — without it, Daniel discloses nothing and the risk assessment fails.

🎓 SCA framing — gentle, non-confronting, curious

"Thanks for coming in — I can see this is hard. I'm not here to judge or to catch you out; I just want to understand what life's been like for you lately. Can you tell me how things have been?"

Don't challenge delusions or argue with them; explore them with curiosity ("that sounds frightening — tell me more about it"). A non-confronting, validating stance is what allows a guarded, paranoid patient to talk, and is the gateway to assessing risk.

1A — Symptoms, risk and causes

Question	Why it matters	Changes what?
🟢 OPEN QUESTION"Tell me how the last few months have been for you — in your own words."	An open, unhurried, non-judgmental opening is the single most important move. It lets Daniel describe the decline and, if trust builds, the delusions and voices. The timeline (months of withdrawal then emerging positive symptoms) is the classic first-episode trajectory.In SCA: rapport-building with a suspicious patient, and exploring rather than challenging beliefs, is heavily rewarded — it's the core skill of the case.	Decline + positive symptoms → first-episode psychosis
Positive symptoms"Some people in your situation have unusual experiences — do you ever hear things others can't, or feel that people might be watching or interfering with you? Can you tell me about the voices?"	Characterise hallucinations (modality, third-person/running commentary, command), delusions (persecutory, reference, control), thought disorder and passivity. Daniel's persecutory delusions and third-person auditory hallucinations are first-rank-type positive symptoms. Explore gently, without endorsing or disputing.	Positive symptoms confirm psychosis; command hallucinations raise risk.	Defines psychosisCommand hallucinations → risk
Negative symptoms & function"How have your motivation, studies, friendships and self-care been? What does a typical day look like now?"	Negative symptoms (apathy, social withdrawal, blunted affect, self-neglect) are often the earliest and most disabling, and are easily mislabelled as depression or "drifting". The functional decline (stopped lectures, lost friends, neglected hygiene) defines severity and need.	Negative symptoms/decline → severity, support needs; differentiate from depression.	Function → support & urgency
🚩 Risk assessment"Have you had thoughts of harming yourself or that life isn't worth living? Do the voices ever tell you to do things? Do you feel anyone means you harm, or that you need to protect yourself?"	Mandatory and central. Assess suicide/self-harm (markedly raised), command hallucinations, intent/plans, risk to others (driven by delusions), self-neglect, vulnerability/exploitation, and safeguarding of dependents. Daniel has passive suicidal thoughts — explore fully and gauge protective factors.	Active risk/command hallucinations/severe neglect → crisis/urgent assessment ± MHA.	Acute risk → crisis team / MHA
🚩 Drugs & organic screen"What are you using — cannabis, stimulants, alcohol? Any new medicines? Any fevers, confusion, head injury, fits, or physical illness?"	High-potency cannabis (Daniel, daily) and stimulants can precipitate/worsen psychosis; steroids/dopaminergics and withdrawal states cause it. Organic causes — delirium, temporal lobe epilepsy, encephalitis, thyroid, B12, SLE, tumour, dementia — must be excluded, especially with acute onset, confusion, fever, focal signs, or older age.	Substance/organic cause → manage substance / medical work-up; new psychosis in older/confused patient = delirium.	Bloods; urine drug screen with consent if it will inform care; ?organic work-up
Background & collateral"Any family history of mental illness? Can I, with your permission, also hear from your mum, who's worried about you?"	Family history (Daniel's uncle) raises risk. Collateral history from family/carers is invaluable for the timeline and risk — seek consent, and balance confidentiality with safety. The mother's account both informs and is part of supporting the family.	Family history → risk; collateral → accuracy; consent for family involvement.	Collateral + family support (consent)

1B — Red flags

🚨

Red Flags — risk and the organic mimics

Red flag	Why dangerous	Action
Active suicidality / command hallucinations to harm self or others	Suicide risk is markedly raised in psychosis; command hallucinations can drive acts.	999 if imminent or unmanageable risk; otherwise same-day crisis/urgent psychiatric assessment; safety plan; consider Mental Health Act if refusing & at risk
Severe self-neglect / inability to care for self / vulnerability & exploitation	Risk to health and safety; safeguarding of patient and any dependents.	Urgent assessment; safeguarding; consider admission
Delirium / organic psychosis — acute onset, fluctuating, clouded consciousness, fever, focal neurology, older age	A medical emergency mislabelled as "psychiatric"; encephalitis, metabolic, structural causes.	Treat as delirium — medical assessment/admission; find & treat the cause
First-episode psychosis (any)	Shorter duration of untreated psychosis improves outcomes; needs specialist assessment, not GP-alone treatment.	Urgent EIP/CMHT referral; do not start antipsychotics alone
Neuroleptic malignant syndrome (in treated patients) — rigidity, fever, autonomic instability, ↑CK	Life-threatening reaction to antipsychotics.	Stop antipsychotic; emergency admission
Clozapine patient with fever/sore throat (neutropenia) or new illness	Agranulocytosis / myocarditis — life-threatening.	Urgent FBC; liaise with the clozapine service; emergency assessment

1C — ICE

💭 Ideas

"What do you make of what's been happening to you — what do you think is going on?"

Daniel may have little insight, or a frightening explanation (the housemates are real to him). Understanding his model lets you meet him where he is — neither colluding with nor flatly contradicting the delusion — and frame help in terms he can accept (stress, sleep, the distress of the voices).

😟 Concerns

"What's been the hardest or most frightening part of all this for you?"

His concern may be fear of the voices, of being watched, or of being "mad"/sectioned. Naming it builds trust, reduces threat, and lets you offer help framed around reducing his distress rather than labelling him.

🎯 Expectations

"What were you hoping might come from today — and what would feel like help to you?"

He may not want help, or fear hospital. Naming this lets you explain the supportive, non-coercive role of the specialist team, address fears about being sectioned, and negotiate engagement — central to a successful, consensual referral.

1D — Psychosocial context

First-episode psychosis usually strikes a young person and their family at once — frightening, stigmatised, and often misread for months as "stress", drugs or laziness. The patient may be terrified, mistrustful, and lack insight; the family is frequently the one raising the alarm and carrying the distress. The consultation matters enormously because earlier treatment improves outcomes (shorter DUP). Success rests on a calm, non-judgmental, hopeful stance: engaging the young person without confrontation, taking risk seriously, supporting the family within the bounds of confidentiality, and getting specialist help moving quickly.

🤝 Engagement over confrontation

Don't argue with delusions; build trust around shared goals (sleep, less distress).

"I can't fully know what you're experiencing, but I can see it's distressing and exhausting. Whatever's behind it, I'd like to help you feel safer and sleep better — can we work on that together?"

👪 The frightened family

Support the mother; seek consent to involve her; signpost carer support.

"I can see how worried you are, and bringing him in was the right thing. With Daniel's permission I'd like to keep you involved — and there's support for families going through this too."

😨 Fear of being "sectioned"

Address the fear of hospital/coercion honestly.

"Most people get help without ever going into hospital — the team I want to involve work with you in the community. My aim is to support you, not to take control away from you."

🌱 Hope & early help

Convey realistic hope — early treatment helps.

"Getting help early genuinely makes a difference to how things go. There are effective treatments and a specialist team for exactly this — you don't have to manage it alone."

1E — Psychosocial context: the person behind the psychosis

🧭

Daniel's world: the student, the son, the cannabis, and the fear of what a diagnosis will mean

The history is not complete when you know the symptoms. You also need to know where Daniel lives and with whom, what he is using and why, who supports him, what he fears, and what he stands to lose. These questions shape both risk and engagement. A young man who is isolated in a shared house with people he believes are spying on him is in a different position from one who can go home to his mother tonight. Ask about each area gently, and in an order he can tolerate.

🏠

Where and with whom he lives

Daniel lives in a shared student house with the housemates he now believes have bugged his room. That matters for risk in both directions. He may feel he has to defend himself, and his housemates may be frightened or hostile. He may also stop eating or sleeping there, or leave suddenly. Ask where he will sleep tonight, and whether staying with his mother for now is possible and acceptable to both of them.

"Where are you staying at the moment? Do you feel safe there? Would going back to your mum's for a while help, or would that make things harder?"

🌿

Cannabis: what it does for him

Daily high-potency cannabis is both a risk factor and, for many young people, a form of self-medication for anxiety, poor sleep or the voices. If you start with a lecture he will disengage. Ask what it does for him, how much he uses, and whether he has noticed any link with how he feels. That gives you the motivational groundwork for a later brief intervention and referral to drug services.

"A lot of people find cannabis helps them switch off or sleep. What does it do for you? Have you noticed whether the voices or the worries change when you smoke more or less?"

🎓

Studies, money and the future

He has stopped attending lectures, so his course, funding and student accommodation may all be at risk. Loss of role is one of the most damaging consequences of a first episode, and returning to education or work is a named recovery goal in NICE CG178. Early contact with the university's student support or disability service, with his consent, can stop him from being withdrawn from the course by default.

"Your course matters. With your permission, I can write something for the university so they understand you've been unwell. That can protect your place while you get help."

👪

Family history and family dynamics

An uncle with schizophrenia raises Daniel's genetic risk. It may also shape what the family fears: "he's going the same way". Explore what they saw happen to the uncle. That experience, whether it was admission, detention or recovery, will colour how they react to the word "psychosis". High expressed emotion at home (criticism, hostility, over-involvement) predicts relapse, so family intervention is part of the treatment, not an optional extra.

"You mentioned your uncle. What happened for him? I ask because families who've seen someone go through this often carry that worry, and it helps me to know."

🌍

Culture, faith and trust in services

How someone understands unusual experiences depends on culture and faith. Young Black men in the UK are also more likely to reach mental health services through crisis, police or compulsory routes, and they and their families may reasonably mistrust services. Ask how Daniel and his family make sense of what is happening, and whether faith or community leaders are part of their support. Show from the start that you want him to have a say in his own care.

"People understand experiences like these in different ways, through faith, stress or family beliefs. How do you and your family make sense of it? I want the help we arrange to fit you."

🔐

Confidentiality and his mother's role

Daniel is an adult, so his information belongs to him. You can always listen to his mother and take a collateral history without breaching confidentiality. Sharing his information with her needs his consent, unless there is a serious risk to him or others that makes disclosure necessary and proportionate. It often helps to see him alone for part of the consultation, then agree with him what can be shared.

"I'd like to speak with you on your own for a few minutes. Then we can agree together what, if anything, you're happy for me to share with your mum."

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"Tell me about the voices — what do they say?" + "Do they ever tell you to do things?" — characterises symptoms and command-hallucination risk.

"Have you had thoughts of harming yourself?" — explicit risk assessment.

"I'm not here to judge or take control — I want to help you feel safer." — engagement.

Deductions

Arguing with / challenging delusions; confrontational stance
Not assessing risk (suicide, command hallucinations, neglect, to others)
Not screening drugs/organic causes
Breaching confidentiality with family without consent (outside risk)

🔴 Red

No risk assessment; confronts delusions; organic/drug causes missed; starts antipsychotic alone; no referral

🟠 Amber

Recognises psychosis; partial risk assessment; some cause screen; referral vague; family/consent partly handled

🟢 Green

Engages without confrontation; characterises positive & negative symptoms; full risk assessment; excludes drug/organic; urgent EIP/CMHT referral; supports family with consent; ICE all three

Step 2

Triage — Crisis/MHA · Urgent EIP/CMHT · Medical (Organic)

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The triage hinge is risk and cause: acute risk or refusal endangering safety needs the crisis team and possibly the Mental Health Act; suspected organic psychosis/delirium needs medical assessment; and a first episode without acute risk needs urgent EIP/CMHT referral. Daniel has a first episode, passive suicidal thoughts with no plan, limited insight, and is physically well. He needs an urgent EIP referral made by phone the same day, with a written safety plan. Because of his passive suicidal thoughts, limited insight and heavy cannabis use, arrange a same-day assessment through the EIP duty worker, or the crisis team or duty psychiatrist if EIP cannot see him today. Escalate to crisis assessment if risk rises.

🔴 Emergency

Same day / crisis

Immediate

Acute risk to self/othersActive suicidality, command hallucinations, violence → crisis team / urgent psychiatry; MHA if needed
Severe self-neglect / refusal endangering safetyUrgent assessment; consider MHA
Suspected delirium / organic causeMedical assessment/admission

🟠 Urgent

Days

EIP / CMHT

First-episode psychosis (no acute risk)Urgent EIP referral; safety plan; same-day crisis/duty psychiatrist assessment if significant distress, poor insight or risk
Relapse of known psychosisCMHT/care coordinator
Significant substance-induced psychosisMH + substance services

🟢 Routine

GP / shared care

Ongoing role

Stable established schizophreniaPhysical-health monitoring; relapse vigilance; adherence
Clozapine shared careBloods; liaise clozapine service
Carer supportFamily intervention; carer's assessment

🎓 SCA Checkpoint — Step 2Tasks

Triage rationale

"You're not in immediate danger today, which is good — so rather than hospital, I want to get you seen urgently by a specialist team that helps young people with exactly these experiences, and we'll make a safety plan in the meantime."

Deductions

Missing acute risk / not escalating to crisis/MHA when needed
Treating organic psychosis as psychiatric
Routine (non-urgent) referral for a first episode

Step 3

Assessment — Mental State · Risk Formulation · Physical/Cognitive Screen

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"Examination" is the mental state examination and risk formulation, plus a physical and cognitive screen to exclude organic causes — clouded consciousness, fever or focal signs point away from primary psychosis.

🧠 Mental state & risk

Domain	What to assess
Appearance/behaviour	Self-care, guardedness, agitation, rapport, response to internal stimuli.
Speech & thought	Form (disorder), content (delusions), possession (insertion/withdrawal/broadcast).
Perception	Hallucinations — modality, third-person, command.
Mood & cognition	Depression/affect; orientation/attention (delirium screen).
Insight & risk	Insight; suicide/self-harm, to/from others, neglect, vulnerability, safeguarding.

⚕️ Physical / organic

Check	Why
Consciousness / cognition	Clouding/fluctuation → delirium.
Vitals, temperature	Infection/encephalitis; NMS in treated patients.
Neurological exam	Focal signs, seizures (temporal lobe).
General/physical baseline	Weight, BP, signs of substance use/withdrawal; baseline for antipsychotics.

🎓 SCA Checkpoint — Step 3TasksGlobal Skills

Demonstrating the formulation

"My assessment is a likely first episode of psychosis — persecutory beliefs and voices on a background of months of withdrawal — with current risk of self-harm low but present, no signs of a physical cause, and heavy cannabis use as a factor. That needs urgent specialist assessment."

Deductions

No explicit risk formulation
No cognitive/physical screen to exclude organic cause

Step 4

Investigations — Exclude Organic · Drug Screen · Antipsychotic Baseline

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Investigations exclude organic causes, screen for substances, and establish a physical-health baseline before antipsychotic treatment — much of this is initiated in primary care or shared with the specialist team.

🧪 Exclude organic / baseline

Test	Why
FBC, U&E, LFTs, glucose/HbA1c, lipids	Organic screen + metabolic baseline before antipsychotics.
TFTs, calcium, B12/folate	Thyroid, metabolic, deficiency causes.
CRP/ESR (± autoimmune)	Only if infection, inflammatory or systemic disease is suspected; autoimmune encephalitis antibodies are specialist-guided.
Prolactin, ECG (QTc)	Prolactin is a CG178 baseline test before antipsychotics. ECG before an antipsychotic if the SPC requires it, examination shows cardiovascular risk, there is a personal history of cardiovascular disease, or the person is being admitted (CG178).
Weight/BMI, BP, smoking	Physical-health baseline (SMI mortality).

🔬 Targeted / specialist

Test	When
Urine drug screen	With consent, where the result will inform management, diagnosis or safety planning — not routine screening (NICE CG120). A positive result does not exclude a primary psychosis; a negative one does not exclude substance-related psychosis.
CT/MRI brain	Focal signs, atypical/late onset, suspected structural/encephalitic cause (specialist).
EEG / LP	Suspected epilepsy/encephalitis (specialist).
Clozapine monitoring	Mandatory FBC schedule in clozapine patients.

🎓 SCA Checkpoint — Step 4Tasks

Key reasoning

"I'll do some blood tests to rule out physical causes like thyroid or infection, and to get a baseline before any medication the specialist might start — and we'll factor in the cannabis use."

Deductions

No organic screen / drug screen
Not establishing a physical-health baseline

Step 5

Diagnosis — Psychosis · Schizophrenia · Organic/Drug · Affective · Differentials

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In primary care the working diagnosis is "first-episode psychosis" — the formal diagnosis (schizophrenia vs other) is the specialist's job after assessment over time. The GP's task is to recognise psychosis, exclude organic/drug causes, and refer; not to apply the schizophrenia label prematurely.

Diagnosis	Discriminating features
First-episode psychosis	Positive ± negative symptoms; the primary-care working diagnosis → refer (Daniel).
Schizophrenia	Characteristic symptoms ≥1 month with functional decline (specialist diagnosis over time).
Drug-induced psychosis	Temporal link to cannabis/stimulants/withdrawal; may resolve but warrants assessment.
Organic psychosis / delirium	Acute, fluctuating, clouded consciousness, fever/focal signs, older age.
Affective psychosis	Severe depression with mood-congruent psychotic features, or bipolar mania/mixed state with psychosis (not necessarily mood-congruent — the link is with the mood episode); urgent psychiatric assessment (NICE CG185).
Other	Schizoaffective, delusional disorder, severe stress/PTSD, autism-related.

🚩 Recognise and refer — don't over-label or under-treat

The GP's job is not to diagnose schizophrenia but to recognise psychosis, exclude organic/drug causes, assess risk, and get specialist help quickly. For Daniel the formulation is a likely first episode of psychosis with heavy cannabis use and a family history, current self-harm risk low but present, no organic red flags — requiring urgent EIP referral, a safety plan, family support with consent, and physical-health baseline, but NOT a GP-initiated antipsychotic or a premature schizophrenia label.

🎓 SCA Checkpoint — Step 5Tasks

Explaining it plainly

"I think you're having experiences doctors call psychosis — the mind can start to perceive threats and voices that feel completely real. It's treatable, and there's a specialist team for young people I want to involve quickly. I won't put a bigger label on it now — that's something they'll work out with you over time."

Deductions

Diagnosing "schizophrenia" prematurely
Not excluding drug/organic causes before labelling

Step 6

Referral — Crisis/MHA · EIP/CMHT · Medical · Substance · Carer Support

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Referral is the core action: urgent Early Intervention in Psychosis / community mental health team for a first episode; the crisis team (and Mental Health Act) for acute risk; medical services for organic causes; substance services where relevant; and carer support for the family.

Referral	Who / when	Urgency
🔴 Crisis team / MHA	Acute risk to self/others, severe neglect, refusal endangering safety.	Same day
EIP / CMHT (urgent)	First-episode psychosis — Early Intervention in Psychosis service (NHS standard targets ages 14–65; NICE CG178: accessible regardless of age), or CMHT. Under 18: CAMHS or EIP per local pathway (CG155). Phone the same day; standard = treatment within 2 weeks.	Urgent
Medical / acute	Suspected delirium/organic psychosis — medical assessment/admission.	Same day
Substance misuse services	Significant cannabis/stimulant use (often jointly with MH).	Soon
Carer / family support	Family intervention; carer's assessment; support organisations.	Routine

🎓 SCA Checkpoint — Step 6Tasks

The key action

"The most important thing today is to get you seen quickly by the Early Intervention team — they specialise in helping young people through exactly this, in the community. I'll make that referral urgently and we'll agree what to do if things feel worse before they see you."

Deductions

Starting an antipsychotic alone instead of referring
Not escalating acute risk to crisis/MHA

Step 7

Management — Expectation · Goals · Psychological & Lifestyle · CG178 Prescribing · Drug Cards · Psychosocial & DVLA · Follow-Up · Monitoring · Safety-Netting

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Immediate primary-care management is a safety plan and an urgent referral, not GP-initiated antipsychotics. Longer term, the GP's roles are central: physical-health monitoring (people with SMI die younger), supporting adherence and relapse prevention, clozapine shared care, and supporting the family — alongside the specialist treatments (antipsychotics, CBT for psychosis, family intervention).

Step 7 at a glance — now and ongoing

🛡️ Immediate (primary care)

Element	Detail
Urgent referral	EIP/CMHT (crisis team/MHA if acute risk) — the key action.
Safety plan	What to do/who to call if worse; crisis numbers; involve family with consent; reduce access to means.
Don't start antipsychotics alone	For first episode, await specialist assessment unless specifically advised.
Address substances	Brief intervention/refer for cannabis; explain its role.
Support & hope	Engage, reduce stigma, instil realistic hope; support the family.

❤️ Longer-term GP role

Element	Detail
Specialist treatment	Antipsychotic (specialist-led), CBT for psychosis, family intervention, psychosocial/vocational support.
Physical-health monitoring	Annual SMI check (CG178): weight/BMI, waist, pulse and BP, glucose/HbA1c, lipids, smoking, alcohol and drugs; ECG and prolactin only where indicated; treat CVD risk (SMI mortality).
Antipsychotic adverse effects	Metabolic, EPSE, prolactin, sedation; NMS awareness; review tolerability/adherence.
Clozapine shared care	Mandatory FBC monitoring; fever/sore throat → urgent FBC; liaise service.
Relapse & carers	Recognise relapse signs; relapse plan; carer support/assessment.

7A — Address the patient's expectation first: validate → explain → negotiate

🤝

Daniel came in expecting to be judged, disbelieved or sectioned. His mother expects a diagnosis and a quick fix. Deal with both expectations before you set out the plan

Validate: name the fear out loud

Daniel's unspoken expectation is that telling a doctor about the voices will lead to hospital or detention. His mother may expect you to "make him take tablets" or to confirm schizophrenia today. If you leave either expectation unspoken, it will undermine the plan. Name them first, calmly and without defensiveness. His challenge, "you're going to get me sectioned", is not hostility. It shows you his main fear.

"I think you might be worried that talking to me today means being taken into hospital. I want to be honest with you: that isn't what I'm planning. From what you've told me, you're not in immediate danger. The help I have in mind is in the community, with you involved in every decision."

Explain: share your reasoning in his terms

You do not need him to accept the word "psychosis" to agree a plan. Frame it around what he does experience: exhaustion, fear, poor sleep, the voices being distressing, and his studies slipping. Explain that a specialist team for young people (Early Intervention in Psychosis) can see him quickly. Explain that getting help early changes how things go, and that no decision about medication will be made without him.

"Whatever is behind it, you're not sleeping, you're frightened, and your course is slipping away. There's a team that works with young people going through exactly this. They see people quickly, and the earlier they're involved, the better things tend to go. Nobody will make you take medication. It's a conversation, and you'd have a say."

Negotiate: agree something he can say yes to today

Offer concrete steps he can accept now: a phone referral to the EIP team today, blood tests to "check your body is OK", help with sleep, a named person to call, and agreement about what his mother can be told. Ask him to choose where he stays tonight. Offer a review within days, not weeks. When he chooses something himself, he is more likely to engage later.

"Can we agree three things today? I'll phone the team this afternoon so you're seen quickly. We'll do some blood tests to check your physical health. And you'll have a number to ring, day or night, if things feel worse. Which of those feels OK to you?"

Key principle: Engagement comes first, and the referral comes from engagement. A GP who "wins" the argument about whether the housemates are really spying loses the patient. A GP who agrees a shared goal (sleep, safety, less fear) gets the referral accepted. For his mother, the honest message is: "The specialists will work out the diagnosis over time. My job today is to make him safe and get him seen quickly, and to make sure you're supported too."

7B — Why treatment matters: goals tailored to this patient

2 weeks

NHS England EIP Access and Waiting Time Standard: at least 60% of people with first-episode psychosis should start a package of care that follows NICE CG178 (NICE QS80) within 2 weeks of referral. Refer the same day, by phone.

15–20 yrs

Shorter life expectancy in people with schizophrenia, mostly from preventable cardiovascular and metabolic disease. The annual physical health check is how primary care narrows this gap.

≥16

Planned sessions of individual CBT for psychosis (CBTp) recommended by NICE CG178, offered alongside medication, not instead of it.

Planned sessions of family intervention over 3 months to 1 year (NICE CG178). Include the person with psychosis where possible. Aims to reduce relapse and support carers.

4–6 wks

Trial of an antipsychotic at optimum dose before judging response (NICE CG178). Starting and changing doses is led by the specialist team.

1–2 yrs

NICE CG178: tell people there is a high risk of relapse if they stop antipsychotic medication in the next 1–2 years. Any stopping should be gradual and planned with the team.

2 drugs

Offer clozapine if schizophrenia has not responded to adequate doses of at least 2 different antipsychotics used in turn, at least 1 of them a non-clozapine second-generation drug (NICE CG178).

3 months

DVLA Group 1: after an acute psychotic episode the person must not drive. They can usually be relicensed once well and stable for at least 3 months, adherent to treatment and free of impairing side effects.

Treatment goals — Daniel's plan

Safe today: risk assessed, written safety plan, crisis numbers held by him and his motherSame-day phone referral to EIP; seen within the 2-week standard Organic and drug causes excluded; physical health baseline done before any antipsychoticAntipsychotic choice made jointly with the specialist team if offered, with side effects discussed openly CBTp and family intervention offered alongside medicationCannabis reduced or stopped; drug service or dual-diagnosis input University place protected; supported return to study (IPS/education support)Added to the practice SMI register; annual physical health check; relapse signature documented with him and his mother

Motivational language — tailored to Daniel

"You told me you want to get back to your course and stop feeling hunted in your own room. That's what we're aiming for. The team I'm referring you to helps young people get back to studying and working. That's part of their job, not an afterthought."

"Many people who get help early for experiences like yours recover well. They finish their studies, work and have relationships. What happened to your uncle isn't a prediction of what will happen to you. Treatment and support are much better now, and you're getting help sooner."

"I'm not going to tell you to stop cannabis today. But I would like you to notice, over the next week or two, whether the voices and the worry change with how much you smoke. Would you be willing to try that?"

7C — Non-medication management: mechanism + evidence + tailored advice

NICE CG178 recommends offering an oral antipsychotic together with psychological interventions (family intervention and individual CBT) for first-episode psychosis. If someone declines medication, still offer the psychological treatments. Most of the interventions below are delivered by the EIP team. The GP's role is to know they exist, recommend them with conviction, and support them over time. For people on antipsychotics, NICE CG178 also recommends a combined healthy eating and physical activity programme and help to stop smoking.

🧠

CBT for psychosis (CBTp)

Target: ≥16 planned sessions, one-to-one

Mechanism

CBTp does not try to argue a person out of their beliefs. It helps them link thoughts, feelings and behaviour to their experiences, look at other explanations, reduce distress, and develop coping strategies for voices and paranoia. It follows a formulation built with the person. It also covers relapse prevention.

Practical

Delivered by the EIP or CMHT psychology team. It can start before, with or without medication. Tell Daniel it is a talking therapy "about what's been happening and how to make it less frightening", not about proving him wrong. Ask about it at every review and encourage him to finish the course.

NICE CG178: offer CBTp to everyone with first-episode or established psychosis, alongside medication

👨‍👩‍👦

Family intervention

Target: 10 planned sessions over 3 months–1 year

Mechanism

Family intervention reduces high expressed emotion (criticism, hostility, emotional over-involvement), which is a well-established predictor of relapse. It also teaches the family about the illness and early warning signs, and improves communication and problem-solving in the household. It supports carers, who are often exhausted and frightened.

Practical

Offer it to families who live with, or are in close contact with, the person (NICE CG178). Include Daniel where possible. His mother is the obvious partner. With consent, refer through EIP. Tell her about carer support (Rethink Mental Illness, local carers' centre) and her right to a carer's assessment.

NICE CG178: recommended for all families of people with psychosis in close contact. Reduces relapse and admission

🌿

Cannabis and substance use

Target: stop, or reduce as a first step; drug service if dependent

Mechanism

High-THC ("skunk") cannabis is associated with a higher risk of developing psychosis, with a dose–response relationship. In the multicentre EU-GEI case–control study (Di Forti et al., Lancet Psychiatry 2019), daily use of high-potency cannabis carried roughly five times the odds of psychotic disorder compared with never using it. Continued use after a first episode is linked to more relapse and admission. Stimulants and alcohol also worsen psychosis.

Practical

Take a non-judgemental, motivational approach. Ask about quantity, potency, route and function. Give a brief intervention at every contact. Refer to local drug services, or to the dual-diagnosis pathway where available. EIP teams usually include substance work. A positive drug screen does not rule out a primary psychotic illness.

Reducing cannabis is the most important change Daniel can make himself

🥗

Healthy eating, activity & smoking cessation

Target: from the start of any antipsychotic, not after weight has been gained

Mechanism

Antipsychotic-induced weight gain is often fastest in the first weeks to months of treatment, especially with olanzapine and clozapine. It is easier to prevent than to reverse. People with psychosis have high smoking rates, and smoking drives much of the cardiovascular part of the mortality gap.

Practical

Offer a combined healthy eating and physical activity programme to people starting antipsychotics (NICE CG178). Offer help to stop smoking with behavioural support and pharmacotherapy. Tell the mental health team first if the person takes clozapine or olanzapine, because tobacco smoke speeds their metabolism (see clozapine card). Use the Lester Positive Cardiometabolic Health Resource (2023 update) to decide when to act on weight, glucose, lipids and blood pressure.

Prevention is easier than reversal: weigh at every early review

💼

Education and employment (IPS)

Target: stay on the course or make a supported return

Mechanism

Having a role (study, work) protects against relapse, social drift and poverty. Individual Placement and Support (IPS) is "place then train": fast, supported entry into real jobs or courses, with ongoing support. It has better outcomes than traditional stepwise vocational rehab.

Practical

NICE CG178 recommends offering supported employment programmes to people who want to find or return to work. Many EIP teams include an IPS worker or education and employment support. With consent, contact the university's disability or wellbeing service early to arrange interruption of studies, extensions or Disabled Students' Allowance, rather than let him be withdrawn for non-attendance.

Returning to study is a recovery goal, not a reward for recovery

😴

Sleep, routine & relapse signature

Target: written relapse-prevention and crisis plan shared with carer

Mechanism

Sleep disruption is both a trigger and an early warning sign of relapse. Each person has a fairly consistent "relapse signature", a sequence of early changes such as poor sleep, withdrawal, irritability and suspiciousness. These often appear a few weeks before florid symptoms return. Noticing them early creates a window to act before crisis.

Practical

Encourage regular sleep and wake times, less caffeine and fewer late-night screens, and no cannabis as a sleep aid. Once he is engaged, record his early warning signs, what helps, and who to call, in a plan that he, his mother, EIP and the practice all hold. Code the crisis plan in the GP record.

Acting on the relapse signature early can prevent crisis and admission

🎨

Arts therapies & peer support

Target: considered by the specialist team, especially for negative symptoms

Mechanism

Negative symptoms (apathy, withdrawal, flattened affect) respond less well to antipsychotics than positive symptoms, but often limit function the most. Arts therapies and peer support give people ways to express themselves, connect with others and rebuild social confidence without relying on talking alone.

Practical

NICE CG178 advises considering arts therapies for people with psychosis, particularly to relieve negative symptoms. They are delivered by HCPC-registered arts therapists through secondary care. Signpost to peer-support and recovery-college courses, which many mental health trusts run.

Negative symptoms: the part of the illness that most affects function

7D — Prescribing guide: NICE CG178 approach to antipsychotic treatment (specialist-led)

NICE CG178: do not start antipsychotic medication in primary care for a first presentation of sustained psychotic symptoms, unless this is done in consultation with a consultant psychiatrist. CG178 does not name a single preferred antipsychotic. The service user and prescriber choose together, taking the carer's views into account if the person agrees. They weigh likely benefits against the drugs' different side-effect profiles: metabolic (weight gain, diabetes), extrapyramidal (akathisia, dyskinesia, dystonia), cardiovascular (QT prolongation), hormonal (raised prolactin) and subjective experience. Doses: per SPC, set by the specialist team. The GP's roles are the baseline, shared-care monitoring, spotting adverse effects and supporting adherence.

Stage	What NICE CG178 says	GP action
At-risk mental stateAttenuated or brief symptoms, distress, functional decline	Refer for specialist assessment without delay (CG178 advises assessment by a consultant psychiatrist or trained specialist with experience in at-risk mental states). Offer individual CBT, with or without family intervention. Do not offer antipsychotic medication to people at increased risk of psychosis, or with the aim of preventing psychosis.	Refer (usually EIP). No antipsychotic. Monitor and safety-net. Address cannabis.
First-episode psychosisDaniel	Early intervention in psychosis services should be accessible to everyone with a first episode or first presentation of psychosis, whatever their age or duration of untreated psychosis. Offer an oral antipsychotic together with psychological interventions (family intervention and individual CBT). If the person wants to try psychological treatment alone, advise that it is more effective combined with medication, and offer it anyway with a review within 1 month.	Same-day phone referral to EIP. Do the baseline. Don't start an antipsychotic yourself unless a consultant psychiatrist has advised it.
Before starting	Baseline weight (plotted on a chart), waist circumference, pulse and BP, fasting glucose, HbA1c, lipids, prolactin, assessment of movement disorders, and nutritional status, diet and physical activity. Offer an ECG if the SPC specifies one, if examination has found a specific cardiovascular risk (for example high BP), if there is a personal history of cardiovascular disease, or if the person is being admitted as an inpatient.	Often done in primary care at referral. Send results to EIP. Add U&E, LFT, FBC and TFT as part of the organic screen.
Starting and titrating	Start at the lower end of the licensed range and titrate slowly within the SPC range. Record the rationale for any dose outside the SPC range. Give a trial at optimum dose for 4–6 weeks. Do not routinely use regular combined antipsychotics except for short periods, such as when switching. Record indications, expected benefits, side effects and adherence.	Record who initiated the drug. Check the shared-care agreement. Watch for early akathisia, dystonia and sedation.
Maintenance & relapse prevention	Tell the person there is a high risk of relapse if they stop medication in the next 1–2 years. If stopping, withdraw gradually and monitor for at least 2 years. Consider a depot/long-acting injectable for people who would prefer one, or where avoiding covert non-adherence is a clinical priority.	Ask about adherence non-judgementally. Tell EIP about missed depots. Pick up early signs of relapse.
Poor response	Review the diagnosis. Check adherence, adequate dose and duration, substance use, and whether psychological treatments have been received. Look for other causes such as prescribed drugs or physical illness.	Share adherence and substance information with the team. Check for interacting drugs.
Treatment-resistant schizophrenia	Offer clozapine if the illness has not responded adequately despite sequential use of adequate doses of at least 2 different antipsychotics, at least 1 of them a non-clozapine second-generation antipsychotic.	Clozapine is started and supplied by secondary care, with registered blood monitoring. The GP records it, knows its interactions, and acts on fever, sore throat or constipation.

Children and young people — NICE CG155

If a child or young person under 18 has suspected psychosis, refer urgently to a specialist mental health service: CAMHS, or EIP where the local pathway accepts under-18s (the EIP standard covers people from age 14). Do not wait for diagnostic certainty.
CG155 advises that antipsychotic medication should not be started in primary care for a first presentation of sustained psychotic symptoms unless done in consultation with a consultant psychiatrist with training in child and adolescent mental health.
Do not offer antipsychotics to young people with transient or attenuated symptoms (at-risk mental state).
Psychological treatment (CBTp, family intervention) is offered with medication. Monitoring is similar to adults, using age-appropriate growth and weight charts.
Think about safeguarding, education (school or college liaison) and the parents' role. Young people aged 16–17 are presumed to have capacity to consent to treatment.

Primary-care prescribing traps with antipsychotics

QT-prolonging combinations: check before adding macrolides, some antidepressants (for example citalopram), ondansetron or methadone to a QT-prolonging antipsychotic. Correct low potassium and magnesium.
Clozapine not visible on the GP record: it is usually supplied by the trust. Record it as a hospital-issued drug so interaction alerts work and out-of-hours clinicians can see it.
Smoking change: stopping smoking (including a switch to vaping), or starting again, changes clozapine and olanzapine levels. Contact the team before a quit attempt.
Anticholinergic load: procyclidine, tricyclics and antihistamines add to constipation, confusion and cognitive effects.
Valproate: sometimes used in schizoaffective disorder or bipolar. It must not be started in anyone under 55 unless two specialists independently document the justification (MHRA, January 2024).
Benzodiazepines: short-term only, if at all. Avoid long-term prescribing for sleep or anxiety in psychosis.

7F — Drug reference cards: antipsychotics and related drugs a GP will meet

These cards support shared care and recognising adverse effects. They are not a guide to starting treatment. Antipsychotic choice is a shared decision led by the specialist team (NICE CG178), and doses are per SPC as set by the prescriber. In general, the drugs differ more in their side effects than in how well they work, which is why the patient's own priorities (weight, sedation, sexual function, movement effects) should drive the choice.

Aripiprazole

Oral tablets / orodispersible / oral solution · monthly long-acting injection

Second-generation · partial D2 agonist

Specialist-initiatedDose per SPC and local formulary

✓ Often chosen when

Weight, metabolic risk or prolactin-related side effects (sexual dysfunction, menstrual disturbance) are the patient's main concerns. It has a relatively favourable metabolic and prolactin profile.

A young person who wants to avoid sedation so they can study or work.

✗ Cautions

History of impulse-control problems: it has been associated with pathological gambling, hypersexuality and compulsive spending. Ask about these specifically.

Cardiovascular disease, seizure history, older people with dementia (increased stroke and mortality risk with antipsychotics as a class).

⚠ Side effects

Akathisia (inner restlessness, pacing), which is easily mistaken for worsening psychosis or agitation. Also nausea, insomnia and headache. Weight gain is less than with olanzapine but can still happen.

🔬 Monitor

CG178 schedule (weight, BP, glucose/HbA1c, lipids). Ask about restlessness and impulse-control behaviours at each review.

💬 Counselling

"Some people feel restless on this, as if they can't sit still. If that happens, tell us. It's a side effect that can be treated, not a sign that you're getting worse. Also let us know if you notice urges you find hard to control, like gambling or spending."

SCA: if a patient on aripiprazole presents "more agitated", think akathisia before relapse. Explore compulsive behaviours sensitively. They are embarrassing to raise and rarely volunteered.

Olanzapine

Oral tablets / orodispersible · long-acting injection (specialist; post-injection delirium/sedation syndrome: observe in a healthcare facility for at least 3 hours after each injection)

Second-generation

Specialist-initiatedDose per SPC and local formulary

✓ Often chosen when

Sedation is useful (severe agitation or insomnia in the acute phase). Good efficacy. Once-daily dosing.

✗ Cautions

Existing obesity, diabetes, dyslipidaemia or strong family history of these. Olanzapine is among the antipsychotics most associated with weight gain and metabolic syndrome.

Smoking changes: tobacco smoke induces CYP1A2, so stopping smoking can raise olanzapine levels and starting can lower them. Tell the team about any change.

⚠ Side effects

Marked appetite increase and weight gain, often early. Hyperglycaemia and new diabetes. Raised lipids, sedation, anticholinergic effects. Prolactin rises at higher doses.

🔬 Monitor

Weight weekly for the first 6 weeks, then glucose, HbA1c and lipids at 12 weeks, 1 year and annually (CG178 minimum). Act early on weight gain: diet and activity programme, and discuss switching or adjuncts with the team.

💬 Counselling

"This medicine can make you much hungrier than usual, and weight can go up quickly in the first few months. That's much easier to prevent than to reverse, so we'll weigh you regularly and get you support with food and exercise from the start."

Ask about weight and metabolic concerns before the specialist appointment. A young man may care a lot about weight gain, and that is a legitimate reason to prefer a different drug.

Risperidone / paliperidone · amisulpride

Risperidone oral and long-acting injection · paliperidone long-acting injection · amisulpride oral

Second-generation · prolactin-raising

Specialist-initiatedDose per SPC and local formulary

✓ Often chosen when

A long-acting injectable is preferred (risperidone or paliperidone depots), and sedation is unwanted.

✗ Cautions

Hyperprolactinaemia is common: galactorrhoea, amenorrhoea, gynaecomastia, erectile or ejaculatory dysfunction and reduced libido, with lower bone density in the longer term. Amisulpride is renally excreted, so adjust in renal impairment (per SPC).

QT prolongation (particularly amisulpride). Risperidone in older people with dementia: increased stroke risk.

⚠ Side effects

Dose-related extrapyramidal effects (parkinsonism, akathisia, dystonia), prolactin effects, weight gain, orthostatic hypotension.

🔬 Monitor

Ask directly about sexual function and menstrual change, because patients rarely volunteer them. Check prolactin if symptomatic. Check baseline and follow-up ECG where indicated.

💬 Counselling

"Some people notice changes in their sex drive, erections, periods, or leaking from the breasts on this medicine. It's a hormone effect. It's common, it's treatable, and it's a very good reason to talk to us rather than just stopping the tablets."

Unreported sexual side effects are a common hidden reason for stopping antipsychotics. Asking about them directly and without embarrassment shows good consulting.

Quetiapine

Immediate-release and modified-release tablets

Second-generation · sedating

Specialist-initiatedDose per SPC and local formulary

✓ Often chosen when

Low risk of prolactin and movement side effects is wanted, for example in someone with previous extrapyramidal problems or Parkinson's disease-related psychosis (specialist use).

✗ Cautions

Not a hypnotic: avoid low-dose "for sleep" use, which exposes people to metabolic risk for little benefit. Postural hypotension and falls. QT prolongation. It is misused in some settings.

⚠ Side effects

Sedation, dizziness, postural hypotension, weight gain and metabolic effects, dry mouth, constipation.

🔬 Monitor

CG178 metabolic schedule. Postural BP if dizzy. Sedation and driving safety.

💬 Counselling

"This can make you drowsy and a bit light-headed when you stand up, especially at first. Get up slowly, and don't drive if you feel sleepy. Remember, too, that you shouldn't be driving at all while you're acutely unwell."

If you inherit a patient on quetiapine "for sleep" without psychosis or bipolar disorder, review the indication and taper it if appropriate.

First-generation antipsychotics & depots

Haloperidol · zuclopenthixol · flupentixol · (depot formulations of these)

First-generation · high EPSE risk

Specialist-ledDose per SPC and local formulary

✓ Used when

A long-acting injectable is needed and the person has responded well to that drug in the past. Some people prefer them after trying other options.

✗ Cautions

Haloperidol: its SPC recommends a baseline ECG before treatment in all patients (QT prolongation). Avoid combining with other QT-prolonging drugs.

Parkinson's disease or Lewy body dementia: severe sensitivity reactions. Avoid.

⚠ Side effects

Acute dystonia (neck spasm, oculogyric crisis, often in the first days and in young men), parkinsonism, akathisia, tardive dyskinesia in long-term use, and hyperprolactinaemia. Neuroleptic malignant syndrome can happen with any antipsychotic.

🔬 Monitor

Movement disorders at every review (AIMS or local tool). ECG. Depot attendance: tell the care coordinator about any missed injection.

💬 Counselling

"If your neck, jaw or eyes suddenly go into spasm, that's a reaction to the medicine called dystonia. It's frightening but treatable. Get seen urgently the same day, through us, 111, or A&E if it's severe."

An acute dystonia presenting in primary care or out of hours needs same-day treatment and a call to the prescribing team. Do not dismiss it as anxiety or "putting it on".

Clozapine

Clozaril · Denzapine · Zaponex. Brand-specific patient monitoring services (CPMS / DMS / ZTAS)

Treatment-resistant schizophrenia only

Hospital-initiated & suppliedDose per specialist / SPC

✓ Indicated when

Schizophrenia has not responded to adequate trials of at least 2 antipsychotics, at least 1 a non-clozapine second-generation drug (NICE CG178). It is the most effective treatment for treatment-resistant schizophrenia and may also reduce suicidality.

✗ Serious risks

Neutropenia and agranulocytosis: mandatory registered blood monitoring. Usually weekly for 18 weeks, then fortnightly to 1 year, then 4-weekly (per the monitoring service; the MHRA announced a review of these requirements in April 2025, so follow the service's current schedule). Fever, sore throat or any infection → urgent same-day FBC and contact the clozapine clinic.

Constipation and gastrointestinal hypomotility: MHRA Drug Safety Update (October 2017) reminded prescribers of a potentially fatal risk of intestinal obstruction, faecal impaction and paralytic ileus. Ask about bowel habit at every contact, treat actively and early, and avoid other constipating drugs where possible.

Myocarditis and cardiomyopathy: highest risk in the first 2 months. Watch for chest pain, tachycardia, breathlessness or fever. Seek urgent assessment.

Toxicity from changing levels: MHRA Drug Safety Update (August 2020) advises monitoring clozapine blood levels in certain situations, including when a patient stops smoking or switches to e-cigarettes, and with infection or interacting drugs. Levels can rise significantly within days.

⚠ Other side effects

Hypersalivation (often at night), sedation, weight gain and metabolic effects, tachycardia, seizures at higher levels, nocturnal enuresis, postural hypotension.

🔬 GP actions

Record clozapine on the GP system as a hospital-issued drug. Remember it in every acute illness. If doses have been missed for more than 48 hours, contact the clozapine clinic before restarting, because re-titration is usually needed. Metabolic monitoring as for all antipsychotics.

💬 Counselling

"Three things to tell us about straight away: a fever or sore throat, because we'll need a blood test the same day; constipation, because on clozapine it can become dangerous quickly; and any plan to stop or cut down smoking or to switch to vaping, because that changes your clozapine level within days."

Classic exam trap: a clozapine patient with a "simple" sore throat, or with constipation "for a week", both need same-day action. So does a patient who has just stopped smoking and is now very drowsy.

Sodium valproate (schizoaffective / bipolar use)

Sodium valproate · valproic acid (semisodium valproate)

MHRA restricted

Specialist onlyDose per SPC and local formulary

✓ Context

Not a treatment for schizophrenia itself. Some patients with schizoaffective or bipolar disorder take it as a mood stabiliser. GPs may be asked to continue it under shared care.

✗ Restrictions

MHRA (January 2024): valproate must not be started in new patients (male or female) under 55 unless two specialists independently consider and document that there is no other effective or tolerated treatment, or that the reproductive risks do not apply.

Women and girls of childbearing potential: Pregnancy Prevention Programme, highly effective contraception, and an annual specialist review with a Risk Acknowledgement Form. Major teratogen, with neurodevelopmental harm.

Men (MHRA Drug Safety Update, September 2024): as a precaution, men taking valproate and their partners should use effective contraception during treatment and for at least 3 months after stopping. Men should not donate sperm during this time. MHRA (February 2025): men already taking valproate no longer need the two-specialist review; it still applies to new starts under 55.

⚠ Side effects

Weight gain, tremor, hair loss, hepatotoxicity, pancreatitis, thrombocytopenia, hyperammonaemia.

🔬 Monitor

LFTs and FBC per SPC and shared-care protocol. Contraception and pregnancy intention at every review in women of childbearing potential.

💬 Counselling

"This medicine can affect a baby's development, so if there's any chance of a pregnancy, for you or your partner, we need to talk about contraception and plan together. Please don't stop it suddenly yourself. Talk to us first."

Never start valproate in primary care. For young men on valproate, remember the MHRA 2024 contraception advice. It is often missed.

7G — Psychosocial impact of the diagnosis: study, driving, family, identity and the law

🤝

Psychosis: the student who fears for his course, the son who fears his uncle's path, and the mother who fears being shut out

A diagnosis of psychosis affects the whole of a young person's life: education, independence, driving, relationships, how they see themselves, and sometimes their liberty. Most people with a first episode make a good or partial recovery, and the GP is often the one professional who stays with them for decades. Deal with these areas early and practically. It builds the trust that later relapse prevention depends on.

🎓

Study, work and money

Encourage him to stay connected with his course. With consent, contact the university's wellbeing or disability service early. An interruption of studies, extensions or Disabled Students' Allowance can protect his place and funding. Fit notes can support a gradual return to work for people who are employed. IPS or employment support through EIP helps people get back into study or work. Signpost benefits advice if he has lost income (Universal Credit, PIP).

"Would it help if I wrote to the university? I don't need to give them details, just enough to protect your place while you're getting help."

🚗

Driving and the DVLA

Tell the patient not to drive while acutely unwell with psychosis. The licence holder must notify the DVLA of a psychotic illness. Group 1 (car): relicensing is usually possible once the person has been well and stable for at least 3 months, is adhering to treatment and has no impairing side effects, with a supportive specialist report where needed. Group 2 (bus/lorry): much stricter. Relicensing needs a longer period of stability than Group 1, with insight, adherence, the minimum effective dose and a consultant psychiatrist's report. Check the current DVLA guidance for the required period. If a patient keeps driving against advice, follow GMC confidentiality guidance on disclosure to the DVLA.

"While you're unwell, it isn't safe to drive, and the law says the DVLA needs to know. Once you've been well and settled on treatment for a few months, most people can get their car licence back."

👪

Family and carers

NICE CG178 advises offering carers an assessment of their own needs, written information about psychosis and services, and a carer-focused education and support programme. Make clear that his mother can always give you information. What you share back depends on Daniel's consent. Ask him regularly, because consent can change as trust grows. Identify her as a carer on the practice record and consider her own health, since carers' own mental health often suffers.

"You're allowed to tell me anything you're worried about, any time. What I can tell you depends on what Daniel agrees to. I'll keep asking him, and you'll have support in your own right."

👤

Identity, stigma and hope

Labels such as "schizophrenic" or "psychotic" carry heavy stigma, and a young person may start to see themselves only through the diagnosis. Use person-first language ("a person experiencing psychosis"). Be accurate about the diagnosis: the formal diagnosis is made by specialists over time. Offer realistic hope: recovery is common, especially with early intervention. Peer support and recovery colleges help people rebuild a sense of who they are beyond the illness.

"This is something that's happening to you. It isn't who you are. Plenty of people go through an episode like this and go on to finish their studies, work and have families."

⚖️

The Mental Health Act: what a GP needs to know

Compulsory assessment is a last resort, used when someone with a mental disorder needs assessment or treatment for their own health or safety or to protect others, and will not accept it voluntarily. It is usually coordinated by an Approved Mental Health Professional (AMHP) with two doctors, one approved under section 12. Section 2: assessment, up to 28 days. Section 3: treatment. Section 136: police power to take someone to a place of safety from anywhere except a private dwelling (Policing and Crime Act 2017 amendment). Section 135: a warrant to enter premises. A GP who knows the patient is often asked to be one of the two medical recommendations. The Mental Health Act 2025 amends the 1983 Act (for example, it raises the detention threshold to risk of serious harm and shortens some treatment-order periods), but its changes are being brought in gradually. Check which provisions are in force locally.

"Being detained in hospital is rare, and it's only used when someone is at serious risk and can't accept help any other way. That isn't where we are. The help I'm arranging is voluntary, and you're part of it."

💞

Relationships, sexual health and contraception

Antipsychotic effects on prolactin and sexual function can quietly damage relationships and adherence. Ask about them directly. For women of childbearing potential, discuss contraception and plans for pregnancy before any antipsychotic or mood stabiliser, and follow the valproate Pregnancy Prevention Programme strictly. For men on valproate, give the MHRA 2024 contraception advice. Remember the vulnerability to exploitation (financial, sexual, drug-related) during acute illness, and safeguard where needed.

"Some of these medicines can affect sex drive or sexual function. People often feel awkward mentioning it, but it's important, and there's usually something we can change."

7H — Follow-up schedule

Today — Same-day referral, baseline and safety plan

Phone the EIP team (or the crisis team or duty psychiatrist if EIP cannot be reached, or if risk, distress or lack of insight make a same-day assessment appropriate). Follow up in writing. Organic screen and physical baseline: bloods, urine drug screen with consent if it will inform care, weight, BP, and ECG where indicated. Offer HIV and syphilis testing if there are risk factors or atypical features. Written safety plan with crisis numbers (local 24/7 mental health line, NHS 111 mental health option, 999), given to Daniel and, with consent, his mother. Agree where he sleeps tonight. Code him on the SMI register once a psychotic disorder is established.

Risk re-assessed before he leavesPhone, not just a letter

Within 1–3 days — Phone or face-to-face check

Has EIP made contact and is an assessment booked? Re-check risk (suicidal thoughts, command hallucinations, safety at the shared house), sleep and cannabis use. Chase the referral if there has been no contact. Escalate to the crisis team if he has deteriorated or cannot be reached and his mother is worried. Review blood results. Act on any organic cause.

No contact → chase / escalateResults reviewed

Within 2 weeks — EIP assessment and care package starts

The EIP standard is that treatment starts within 2 weeks of referral. A care coordinator is allocated and psychological interventions are offered. If an antipsychotic is started, the specialist team leads early monitoring (weight weekly for the first 6 weeks, side effects, adherence). The GP keeps offering an open door, coordinates physical health, and supports his mother.

Care coordinator namedEarly EPSE / akathisia watch

12 weeks and 1 year — Metabolic checks and recovery review

Per NICE CG178: weight, pulse and BP, fasting glucose, HbA1c and lipids at 12 weeks, and again at 1 year. Check who does them (EIP or GP) under the local shared-care arrangement. Use the Lester tool to decide on interventions. Review cannabis and smoking, return to study, and the relapse signature and crisis plan. Recheck DVLA status if he wants to drive.

Lester toolRelapse signature documented

Annually, lifelong — SMI physical health check

Once monitoring passes to primary care, NICE CG178 says the GP should monitor physical health at least annually. The NHS England SMI health check covers BMI, BP, glucose/HbA1c, lipids, smoking and alcohol, plus relevant follow-up interventions. Also cover QRISK3 (which includes SMI and atypical antipsychotic use), medication review and adherence, sexual health, dental and eye health, cancer screening uptake, and the carer's wellbeing. Invite him proactively and follow up missed appointments: people with SMI often miss checks.

Chase non-attendersSMI register recall

7I — Monitoring: antipsychotic physical health schedule + safety bloods

Memory rule — "weight weekly for 6, then 12 weeks, 1 year, every year"

For anyone starting an antipsychotic, NICE CG178 sets baseline checks, then weight weekly for the first 6 weeks, then at 12 weeks, 1 year and annually. Pulse, BP, fasting glucose, HbA1c and lipids are checked at 12 weeks, 1 year and annually. Waist circumference is checked annually. In addition: prolactin at baseline and if symptomatic, an ECG when indicated, movement disorders at every review, and for clozapine, registered FBC monitoring, bowel habit and levels when smoking status changes.

Parameter	Timing	Action threshold / response
Weight / BMI (plotted on a chart)	Baseline; weekly for first 6 weeks; 12 weeks; 1 year; annually (CG178)	Rapid early weight gain → start the healthy eating and activity programme, review with the team (dose, switch, or adjuncts such as metformin as a specialist decision), and follow the Lester tool.
Waist circumference	Baseline; annually (CG178)	Central adiposity adds to cardiometabolic risk. Use it alongside BMI, especially in South Asian, Chinese, Black African and African-Caribbean patients, where risk starts at a lower BMI.
Pulse & BP	Baseline; 12 weeks; 1 year; annually (CG178)	Manage hypertension per NICE NG136. Persistent tachycardia on clozapine → consider myocarditis early in treatment. Postural drop → review the dose with the team.
Fasting glucose / HbA1c	Baseline; 12 weeks; 1 year; annually (CG178)	HbA1c 42–47 mmol/mol = non-diabetic hyperglycaemia (lifestyle intervention, annual recheck). HbA1c ≥48 mmol/mol = diabetes (confirm and manage per NICE NG28). Tell the prescribing team.
Lipids & QRISK3	Baseline; 12 weeks; 1 year; annually (CG178)	QRISK3 includes SMI and atypical antipsychotic use. Offer statin treatment per NICE NG238 thresholds. Don't under-treat because of the psychiatric diagnosis.
Prolactin	Baseline (CG178); then if symptomatic or per local protocol	Symptoms (galactorrhoea, amenorrhoea, sexual dysfunction, gynaecomastia) → check prolactin and discuss with the team (dose reduction, switch). Very high levels, or high levels with headache or visual symptoms → consider pituitary causes.
ECG	Before starting if the SPC requires it, there is CV risk or disease, or the person is an inpatient (CG178); after dose increases of QT-prolonging drugs	A prolonged QTc (local thresholds vary, typically over about 440–450 ms in men or 470 ms in women; over 500 ms, or a rise of more than 60 ms, is a clear concern) → seek specialist advice before starting or continuing the drug. Check potassium, magnesium and interacting drugs.
Movement disorders	Baseline; each review	Akathisia, parkinsonism, dystonia or tardive dyskinesia → prescribing team review. Treat acute dystonia the same day.
Clozapine — FBC / neutrophils	Per registered monitoring service (typically weekly for 18 weeks, fortnightly to 1 year, then 4-weekly)	Fever, sore throat or infection → same-day FBC and call the clozapine clinic. "Red" result → clozapine stopped per the service protocol.
Clozapine — bowels & levels	Bowel habit at every contact; levels as advised (MHRA DSU August 2020)	Constipation → treat actively and early. Absolute constipation, abdominal pain or vomiting → emergency assessment (ileus or obstruction). Stopping smoking or switching to vaping, infection, or new signs of toxicity → contact the team to check levels and adjust the dose.
Smoking, alcohol, substances	Every contact; annual SMI check	Brief intervention. Cessation support. Drug and alcohol services. Tell the team before a smoking quit attempt if the patient takes clozapine or olanzapine.
Mental state & relapse signature	Every contact	Early warning signs (sleep loss, withdrawal, suspiciousness) → contact the care coordinator the same day. Command hallucinations, active suicidal intent or organic features → crisis pathway or 999.

7J — Safety-netting: exact phrases + medico-legal rationale

⚠ Three scenario-specific safety-nets — adapt the wording, keep the content

What to document — and why it protects the patient and you

Risk assessment: suicidal ideation (passive or active, plan, intent), command hallucinations, harm to or from others, self-neglect, vulnerability, safeguarding of dependants. State the formulation and why you chose that level of urgency.

Referral: EIP contacted by phone on [date/time], name of the person spoken to, agreed timescale. Written referral sent. Plan to chase if there is no contact.

Consent and confidentiality: what Daniel agreed can be shared with his mother. Collateral history taken. Any disclosure made without consent, and its justification (serious risk).

Organic screen: examination findings (conscious level, temperature, neurology), bloods, urine drug screen, and ECG where indicated. Results reviewed and actioned.

Crisis plan: written safety plan given to the patient and carer, with crisis line numbers, 999/A&E advice, and means restriction discussed.

Driving: advised not to drive while unwell, and told of the duty to notify the DVLA. Documented at each relevant review.

TodayPhone EIP (crisis team if risk escalates); baseline bloods and urine drug screen; written safety plan to patient and mother

1–3 daysCheck-in call; confirm EIP contact; re-check risk; chase or escalate

OngoingShared-care metabolic monitoring (12 weeks, 1 year, annually); SMI register; relapse signature; carer support

💬 Key phrases for the consultation

💭 Exploring, not challenging

"I can't hear what you're hearing, but I believe it's very real and very frightening for you. Tell me more about when the voices are worst."

😟 The fear of sectioning

"Most people who see this team are never admitted to hospital. Being detained is only for when someone is at serious risk and can't accept help any other way. That isn't where we are today."

🎯 Medication — a shared decision

"I'm not going to start any medication today. If the team suggests it, there are several options with different side effects. You'd choose together, based on what matters most to you, whether that's weight, feeling sleepy, or side effects on sex drive."

🤝 Supporting mum within consent

"Thank you for bringing him in. That took courage. You can always tell me your worries. What I share back depends on what Daniel agrees, and you're entitled to support as a carer in your own right."

🌿 Cannabis without the lecture

"I'm not here to tell you off about cannabis. But the strong stuff can make voices and paranoia worse for some people. Would you be willing to notice whether cutting down makes any difference?"

📋 Closing the safety-net

"Can you tell me in your own words what you'll do if the thoughts of harming yourself get stronger tonight? And who you'd call?"

🔴🟠🟢 RAG marking — all three domains

Tasks

🟢

Positive and negative symptoms characterised. Full risk assessment (suicide, command hallucinations, others, neglect, vulnerability). Organic and drug screen with a plan for bloods, urine drug screen with consent where useful, and ECG where indicated. Same-day phone referral to EIP (crisis team if risk escalates). No GP-started antipsychotic. Written safety plan. Cannabis addressed. Physical health baseline and long-term GP role stated.

🟠

Psychosis recognised and referral made, but only routinely or by letter. Risk assessment partial (suicide asked, command hallucinations not). Organic screen mentioned but vague. No written crisis plan. Physical health not mentioned.

🔴

No risk assessment. Antipsychotic started alone. "Stress" or "just cannabis" diagnosed without referral. Organic causes not considered. No safety-net.

Relating to Others

🟢

Calm, curious and non-confronting. Beliefs explored without collusion or argument. Fear of sectioning named and addressed honestly. Consent for sharing with mum negotiated, part of the consultation done alone. Mother supported and signposted. ICE explored. Shared decisions.

🟠

Kind but talks mainly to the mother. Consent not explicitly sought. Fear of hospital reassured away rather than explored. Plan explained but not negotiated.

🔴

Tells Daniel his beliefs are "not real". Threatens or implies detention. Breaches confidentiality without justification, or shuts the mother out completely.

Global Skills

🟢

Structured despite a guarded patient and a worried carer. Manages the three-way consultation. Signposts clearly. Uses time well: risk and referral are never squeezed out. Checks understanding of the safety-net.

🟠

Covers the content but loses structure. Runs out of time before the safety plan.

🔴

Disorganised. The mother dominates the consultation. Leaves without a plan or follow-up.

⛔ Danger zones — common errors and the fix

Starting an antipsychotic yourself "to settle him"

NICE CG178: not in primary care for a first presentation unless in consultation with a consultant psychiatrist. Refer urgently and do the baseline instead.

Routine letter referral for a first episode

Phone EIP the same day. The standard is treatment within 2 weeks. Use the crisis team or duty psychiatrist if risk, distress or lack of insight need same-day assessment.

"It's just the cannabis — stop smoking and see"

Substance use and primary psychosis often co-exist. A positive drug screen does not rule out a psychotic disorder. Refer and address cannabis in parallel.

Arguing with the delusion

Explore with curiosity and empathise with the distress. Agree shared goals (sleep, safety, studies) without colluding.

Missing organic psychosis

Check temperature, conscious level, cognition and neurology. Acute onset, fluctuation, seizures, focal signs or older age point to a medical cause → same-day medical assessment.

Clozapine sore throat or constipation treated as minor

Fever or sore throat → same-day FBC. Constipation → active treatment and a low threshold for emergency assessment (MHRA, October 2017). Smoking change → check levels (MHRA 2020).

Leaving physical health to the mental health team

SMI register, annual checks, QRISK3, statins and diabetes care are primary care's job. A 15–20 year mortality gap is not someone else's problem.

Starting or continuing valproate without checks

MHRA 2024: no new starts under 55 without two specialists. Pregnancy Prevention Programme for women. Contraception advice for men.

Forgetting driving

Advise no driving while unwell, and the duty to tell the DVLA. Group 1 relicensing usually after 3 months of stability. Group 2 is much stricter.

🎓 SCA Checkpoint — Step 7TasksRelating to OthersGlobal Skills

A plan that scores

"Here's the plan: an urgent referral to the Early Intervention team today, some blood tests, and a clear plan for if things feel worse — including who to call. With your permission I'll keep your mum involved. I won't start medication myself; the specialists will discuss that with you. We'll also look after your physical health along the way."

Deductions

Starting an antipsychotic alone for a first episode
No safety plan / no physical-health consideration
Excluding the family entirely, or breaching confidentiality without consent (outside risk)

(Guarded, arms folded, glancing at the door) "I don't really want to be here — my mum made me come. There's nothing wrong with me. I just want people to leave me alone."

Who you are

Daniel Osei, 21, university student, brought by your worried mum. Over 4–5 months you've withdrawn — stopped lectures, stopped seeing friends, stopped looking after yourself. In the last few weeks you've become convinced your housemates are spying on you and have bugged your room, and you hear two voices commenting on what you're doing (talking about you in the third person). You sleep badly and smoke strong cannabis every day. An uncle has schizophrenia. You've had fleeting thoughts you'd be "better off dead" but no plan. You're guarded and suspicious; you'll only open up if the doctor is calm, patient and clearly not trying to trap or judge you. You don't think you're ill and you're scared of being "locked up".

Hidden concerns (reveal if explored, slowly)

Fear of the voices / being watched (main): it's frightening and exhausting; if the doctor is gentle, you admit how distressing it is.

Fear of being sectioned: you worry that admitting things means hospital. Reassurance about community help lowers your guard.

Passive suicidal thoughts: you'll disclose these only if asked directly and kindly; no current plan.

Cannabis: you don't connect it to how you feel; defensive if lectured.

Clinical details if asked (and trust is built)

Persecutory beliefs (housemates spying/bugging); third-person auditory hallucinations commenting on you
4–5 months of withdrawal, stopping studies/friends, self-neglect (negative symptoms)
Daily high-potency cannabis; poor sleep; family history (uncle with schizophrenia)
Passive thoughts of being better off dead; no plan/intent; voices don't (currently) command harm
No fever, confusion, head injury, fits; physically well; not on medications

Reactions at key moments

If confronted/contradicted ("that's not real"): you shut down, become more guarded.
If explored gently ("that sounds frightening — tell me more"): you slowly open up.
On risk questions asked kindly: you admit the dark thoughts.
On "community team, not hospital": you relax a little and become more willing.
Challenge line: "You think I'm crazy, don't you? Are you going to lock me up?"

"You think I'm mad, don't you? Is that what this is — you're going to get me sectioned and locked away?"

Resolution: Daniel engages if the GP: (1) builds rapport with a calm, non-judgmental, non-confronting manner and explores his experiences without arguing; (2) characterises the positive and negative symptoms and conducts a thorough risk assessment (suicide, command hallucinations, neglect, to/from others); (3) excludes organic/drug causes (cannabis, delirium) with history and baseline bloods/drug screen; (4) refers him urgently to the Early Intervention in Psychosis team rather than starting an antipsychotic in primary care, and makes a safety plan; (5) supports his mother with his consent, addresses his fear of being sectioned, and instils hope. He disengages and discloses nothing if confronted, judged, or threatened with hospital.

🏥

Clinic Quick Reference

Psychosis & Schizophrenia — Clinical Decision Framework

CG178 · recognise · risk · exclude organic · refer EIP

▼expand

🚦 1 — Recognise & triage

Suspected psychosis

▼

🔴 Emergency

Acute risk self/others; severe neglect; refusal + risk
Delirium / organic cause

Crisis/MHA · medical

🟠 Urgent

First-episode psychosis (no acute risk)
Relapse

Urgent EIP/CMHT

🟢 GP role

Stable SMI: physical-health checks
Clozapine shared care; carers

Monitor

💊 2 — Act

Don't start antipsychotics for a first episode in primary care — refer urgently to EIP/CMHT (shorter DUP = better outcomes). Exclude organic/drug causes (delirium, cannabis/stimulants, thyroid/B12/encephalitis). Assess risk (self/others/neglect/safeguarding); safety plan. Involve family (consent). Ongoing GP role: annual physical-health monitoring (SMI mortality), antipsychotic adverse effects, clozapine bloods, relapse prevention, carer support; CBT & family intervention alongside medication.

🎓

SCA Quick Reference

Psychosis & Schizophrenia — Consultation Playbook

Engage · assess risk · exclude organic · refer EIP · don't treat alone

▼expand

🎯 The three pivots that pass this case

1 · Engage & assess risk

Build rapport, don't confront delusions; assess suicide, command hallucinations, neglect, risk to/from others.

2 · Exclude organic/drug

Cannabis/stimulants, delirium, thyroid/B12/encephalitis — new psychosis in the older/confused = delirium.

3 · Refer, don't treat alone

Urgent EIP/CMHT (shorter DUP = better); safety plan; involve family (consent); GP does physical-health monitoring.

⛔ Don't argue with or challenge delusions · Don't skip the risk assessment (self/others/neglect/safeguarding) · Don't miss organic/drug causes or call delirium "psychiatric" · Don't start antipsychotics for a first episode in primary care — refer urgently (EIP) · Don't breach confidentiality with family without consent (unless risk requires); do support them · Remember physical-health monitoring (SMI mortality) and clozapine bloods

Psychosis & Schizophrenia · GP Clinical Reasoning Framework v2 · NICE CG178 Psychosis and schizophrenia in adults (2014) · NICE CG155 Psychosis and schizophrenia in children and young people · NICE QS80 · NICE NG10 Violence and aggression (2015) · NHS England EIP Access and Waiting Time Standard · MHRA Drug Safety Updates (clozapine 2017, 2020; valproate 2024) · Mental Health Act 1983, as amended by the Mental Health Act 2025

Refer suspected first-episode psychosis urgently to EIP/CMHT — don't start antipsychotics alone (shorter duration of untreated psychosis improves outcomes) · Exclude organic/drug causes (delirium, cannabis/stimulants, thyroid/B12/encephalitis); new psychosis in the older/confused = delirium until proven otherwise · Assess risk to self, from/to others, self-neglect, vulnerability and safeguarding; consider crisis team/MHA for acute risk · Involve family/carers with consent · Ongoing GP role: physical-health monitoring (SMI mortality), antipsychotic adverse effects, clozapine bloods, relapse prevention; CBT & family intervention alongside medication

Teaching clinicians why each step matters — not just what to do · Always consult current NICE CG178 guidance and the Mental Health Act · Clinical judgement takes precedence over any framework

Psychosis & Schizophrenia

Red Flags — risk and the organic mimics

🤝 Engagement over confrontation

👪 The frightened family

😨 Fear of being "sectioned"

🌱 Hope & early help

Where and with whom he lives

Cannabis: what it does for him

Studies, money and the future

Family history and family dynamics

Culture, faith and trust in services

Confidentiality and his mother's role

Same day / crisis

Days

GP / shared care

🚩 Recognise and refer — don't over-label or under-treat

Validate: name the fear out loud

Explain: share your reasoning in his terms

Negotiate: agree something he can say yes to today

Study, work and money

Driving and the DVLA

Family and carers

Identity, stigma and hope

The Mental Health Act: what a GP needs to know

Relationships, sexual health and contraception

Today — Same-day referral, baseline and safety plan

Within 1–3 days — Phone or face-to-face check

Within 2 weeks — EIP assessment and care package starts

12 weeks and 1 year — Metabolic checks and recovery review

Annually, lifelong — SMI physical health check

Memory rule — "weight weekly for 6, then 12 weeks, 1 year, every year"

⚠ Three scenario-specific safety-nets — adapt the wording, keep the content

What to document — and why it protects the patient and you

🎭 Patient actor brief — click to practise

Who you are

Hidden concerns (reveal if explored, slowly)

Clinical details if asked (and trust is built)

Reactions at key moments