Acute medical workup for new‐onset psychosis in children and adolescents: A retrospective cohort

Abstract

No consensus exists about which medical testing is indicated for youth with newonset psychotic symptoms. We conducted a chart review of youths aged 7-21 years who were medically hospitalized for workup of new-onset psychotic symptoms from January 2017 through September 2020 in a free-standing children's hospital. The sample included 131 patients. At discharge, 129 (98.5%; 95% confidence interval [CI]: 94.5-99.8) were diagnosed with a primary psychiatric condition, 1 was diagnosed with levetiracetam-induced psychosis, and 1 with seronegative autoimmune encephalitis. Notably, 33 (25.2%; 95% CI: 18.0-33.5) had incidental findings unrelated to psychosis, 14 (10.7%; 95% CI: 6.0-17.3) had findings that required medical intervention but did not explain the psychosis, 12 (9.2%; 95% CI: 4.8-15.5) had a positive urine drug screen, and 4 (3.1%; 95% CI: 0.8-7.6) had a neurological exam consistent with conversion disorder. In conclusion, extensive medical testing in the acute setting for psychosis had a low yield for identifying medical etiologies of new-onset psychotic symptoms. BACKGROUNDRecommendations for medical workup of psychosis vary. [1][2][3][4][5] Since psychotic disorders are rarely present in youth, children and adolescents with new psychosis symptoms frequently receive medical evaluation. 6 Evaluating psychotic symptoms while minimizing risks associated with medical testing is challenging. Experts agree that evaluation of new-onset psychotic symptoms should include medical, psychosocial, medication/substance, and family histories, physical, and neurologic examination; however, recommendations beyond this are mixed. Benjamin et al. 3 recommend routine laboratory tests. Other groups, including Skikic and Arriola, 4 recommend additional testing, including electroencephalogram (EEG) and baseline/monitoring labs in case antipsychotics

Approach to New-Onset Psychosis in Pediatrics: A Review of Current Practice and an Interdisciplinary Consensus-Driven Clinical Pathway at a Single-Center Institution

“…In one recent single-center retrospective chart review of 131 patients aged 7-21 years hospitalized over a 4-year period for new-onset psychotic symptoms, all but 2 ultimately received a primary psychiatric diagnosis, whereas 10.7% had medical findings that required intervention, even if they did not explain psychotic symptoms. 17 The most commonly performed laboratory tests included basic metabolic panel (96.9%), liver function tests (96.1%), thyroid-stimulating hormone (95.4%), complete blood count (94.7%), and urine drug screen (91.6%). Other testing included brain magnetic resonance imaging (MRI; 74.8%), head computed tomography (CT; 26.7%), routine electroencephalography (EEG; 49.6%), prolonged EEG (15.3%), and lumbar puncture with cerebrospinal fluid testing (46.6%).…”