PS4.1 | Schizophrenia at Primary Care Level — Summary & Reflection

KEY TAKEAWAYS

Schizophrenia at Primary Care — Key Takeaways

Symptom clusters:
- Positive: delusions, hallucinations, thought disorder, disorganised behaviour
- Negative (5As): avolition, alogia, anhedonia, affective flattening, asociality
- Cognitive: working memory, attention, executive function impairments

Aetiology: Neurodevelopmental, multifactorial — dopamine hypothesis (mesolimbic excess → positive symptoms; mesocortical deficit → negative/cognitive symptoms) + glutamate NMDA hypofunction; heritability ~80%; risk factors include cannabis, prenatal infections, urban birth, obstetric complications.

Diagnostic duration — cite the system:
- ICD-11: ≥1 month of core active symptoms
- DSM-5: ≥6 months total (including prodrome), with ≥1 month active phase

Mental Status Examination: Assess appearance, speech, mood/affect, thought content, thought form, perceptions, cognition, insight and judgement — systematically, every patient.

Management at primary care:
- First-line: atypical (second-generation) antipsychotics (risperidone, olanzapine, quetiapine, aripiprazole, amisulpride)
- Typicals (haloperidol, chlorpromazine): effective; higher EPS burden
- Clozapine: treatment-resistant ONLY; mandatory ANC monitoring; specialist initiation
- Monitoring: metabolic (weight, fasting glucose, lipids) for all SGAs
- NMS emergency: fever + lead-pipe rigidity + autonomic instability + raised CK → stop antipsychotic, emergency referral
- Psychosocial: family psychoeducation, community care, CBTp at tertiary level

When to refer: first presentation, treatment failure, suicidality, diagnostic uncertainty, clozapine need, comorbid substance use.

Mental Healthcare Act 2017: governs involuntary admission, advance directives, nominated representative — supersedes the Mental Health Act 1987.

REFLECT

Think back to the young engineering student in the opening scenario. Now that you have completed this module, write a brief (5-minute) reflective note addressing: What aspects of his presentation should have immediately alerted you to a psychotic illness? What investigations would you order to exclude organic causes before labelling him with schizophrenia? Which antipsychotic would you start, at what dose, and what specific adverse effect would you monitor most urgently in the first month? How would you explain the diagnosis and the treatment plan to his parents in plain language that respects their distress without creating false hope or excessive alarm? Finally, consider: what barriers in your clinical environment — stigma, poor mental health literacy, limited specialist access — might prevent this patient from receiving optimal care, and how might you as a primary care physician address even one of those barriers?