A 28-year-old man from Delhi presents to the psychiatry outpatient department with a 3-month history of hearing voices commenting on his actions, believing that his thoughts are being broadcast on television, and social withdrawal. He has no prior psychiatric history and denies substance use. On mental status examination, he is coherent but preoccupied. His family reports progressive functional decline. What is the most appropriate next step in management?

Explanation

## Baseline Investigations Before Antipsychotic Initiation **Key Point:** Before starting any antipsychotic medication in a patient with first-episode psychosis, baseline investigations are mandatory to establish a safety profile and identify metabolic or endocrine contraindications. ### Required Baseline Investigations | Investigation | Rationale | | --- | --- | | Complete Blood Count (CBC) | Screen for cytopenias; baseline for monitoring agranulocytosis risk with clozapine | | Liver Function Tests (LFT) | Assess hepatic metabolism capacity; antipsychotics are hepatically metabolized | | Renal Function Tests (RFT) | Evaluate renal clearance; important for drug dosing and safety | | Fasting Glucose | Baseline for metabolic monitoring; antipsychotics increase diabetes risk | | Lipid Profile | Baseline for metabolic syndrome screening; antipsychotics cause dyslipidemia | | Prolactin Level | Baseline before dopamine antagonists; helps differentiate medication-induced hyperprolactinemia later | | ECG (if available) | Screen for QTc prolongation, especially with haloperidol or ziprasidone | **High-Yield:** The Indian Psychiatric Society and NICE guidelines recommend baseline investigations BEFORE antipsychotic initiation in first-episode psychosis. These investigations inform medication choice and establish safety parameters for long-term monitoring. ### Clinical Pearl Starting antipsychotics without baseline investigations risks: - Missing pre-existing metabolic abnormalities - Inability to attribute later abnormalities to medication vs. disease - Delayed detection of serious adverse events (e.g., agranulocytosis, hepatotoxicity) - Medico-legal liability **Warning:** Do NOT start antipsychotics empirically without baseline labs, even in urgent settings. If psychosis is severe and immediate treatment is needed, baseline labs should be drawn simultaneously with medication initiation, not deferred. ### Why This Patient Needs Baseline Labs This 28-year-old has: - First-episode psychosis (high risk for metabolic complications with antipsychotics) - No prior psychiatric history (no previous medication exposure to reference) - Functional decline requiring antipsychotic therapy - Need for informed choice between first-generation (FGA) and second-generation (SGA) agents [cite:Harrison 21e Ch 386] [cite:Kaplan & Sadock's Synopsis of Psychiatry 11e Ch 5]