Harm minimization from substance abuse

The use of substances such as alcohol, cannabis, and crystal methamphetamine is widespread, and poses significant challenges for treatment providers. Substance use can trigger first-episode and also relapse of psychotic symptoms, often presenting in crisis (Grant et al., 2012).

A comprehensive assessment, including physical examination and mental health review, is essential for determining the most appropriate approach to minimizing substance use. Early engagement and intervention should be incorporated into a comprehensive and tailored treatment plan, which the patient can assist in developing. Treatment should focus on controlling medical and psychiatric symptoms while eliminating the offending substance, or reducing its impact when cessation is not possible.

Maintenance of good physical health

Patients with psychosis tend to experience poor physical health (Kulkarni et al., 2013). It is critical to address physical health early in the course of psychosis. Obesity and tobacco smoking are significant factors in this cohort’s high mortality (Thornicroft, 2011). Weight gain due to medication side effects requires patient education, and ongoing monitoring with the goals of prevention and early intervention. The modification of lifestyle factors such as diet, exercise, alcohol consumption, and smoking is important, and PCPs are ideally placed to have an impact on outcomes related to these factors (Kulkarni et al., 2013). Smoking alters the concentration-to- dose ratio of some antipsychotics (e.g. olanzapine, clozapine, haloperidol), therefore smoking reduction or cessation warrants the appropriate adjustment of antipsychotic dose (Tsuda, 2014).

Many of the psychotropic medications prescribed to patients with psychosis increase risk of serious adverse events. An important role of the PCP is to regularly monitor adverse events, paying particular attention to cardiovascular and metabolic side effects, as well as extrapyramidal effects, with prompt intervention and/or referral as required. A range of other side effects (e.g. sexual, endocrine, sedative) should be routinely assessed and managed accordingly.

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