A 28-year-old man from Delhi presents to the psychiatry outpatient department with a 6-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. On mental status examination, he is coherent but guarded. His insight into illness is poor. What is the most appropriate next step in management?

Explanation

## Management of First-Episode Psychosis (FEP) **Key Point:** Before initiating antipsychotic therapy in first-episode schizophrenia, baseline investigations and informed consent are mandatory. This patient has clear psychotic symptoms (auditory hallucinations, thought broadcasting) meeting criteria for schizophrenia, but lacks prior treatment exposure. ### Why Baseline Investigations Matter **High-Yield:** The sequence is: 1. Establish diagnosis clinically 2. Obtain baseline metabolic and endocrine parameters (prolactin, glucose, lipids) 3. Rule out medical/neurological mimics if clinically indicated 4. Obtain informed consent discussing side effects 5. Initiate antipsychotic at therapeutic dose ### Baseline Investigations Rationale | Investigation | Rationale | |---|---| | **Prolactin** | Baseline before dopamine antagonist; monitor for hyperprolactinemia | | **Fasting glucose & lipids** | Antipsychotics cause metabolic syndrome; establish baseline | | **EEG** | Rule out seizure disorder mimicking psychosis (though not always mandatory) | | **Renal/hepatic function** | Assess drug metabolism capacity | | **Weight & BMI** | Baseline for metabolic monitoring | **Clinical Pearl:** Poor insight (as in this patient) does NOT bypass the need for informed consent — capacity assessment and supported decision-making are essential even when insight is limited. **Mnemonic: BASELINE** — **B**lood tests (glucose, lipids, prolactin), **A**ssess capacity & consent, **S**creen for medical mimics, **E**CG (if on antipsychotics with cardiac risk), **L**iver/renal function, **I**nform about side effects, **N**euroimaging if indicated, **E**stablish therapeutic alliance. ### Why Immediate Antipsychotic Without Baseline is Suboptimal Starting risperidone without baseline data: - Misses opportunity to detect pre-existing metabolic abnormalities - Cannot distinguish drug-induced prolactin elevation from baseline - Violates informed consent principles - May delay detection of medical comorbidities [cite:Kaplan & Sadock 11e Ch 295]