First-episode psychosis in a young man who declines admission

Immediate priorities

• Safety: a low-stimulus, observable space with staff who are calm and consistent; involve security only if needed. He has already climbed onto a roof, so risk of accidental injury is real.
• Risk assessment, asked directly: suicidal ideation, plans, intent, access to means, command hallucinations, thoughts of harm to others, and his capacity to keep himself safe. The statement that others would be 'better off without him' is a passive death wish and must be explored, not accepted at face value. Ask what 'being tested' means to him.
• Self-neglect: three nights without sleep, 7 kg weight loss, not eating, a pulse of 112 - he meets the threshold for seriously diminished capacity to care for himself.
• Collateral history: from the flatmates and then the parents - premorbid function, prior episodes, developmental and forensic history, substance use, head injury, seizures.

Physical work-up before calling it primary psychosis

• Observations, capillary glucose, urine dipstick and midstream urine, pregnancy test where relevant.
• Bloods: FBC, CRP, U&E, LFTs, calcium, thyroid function, glucose, B12 and folate, and HIV and syphilis serology.
• Urine drug screen - cannabis, methamphetamine, synthetic cannabinoids - since a substance-induced psychosis is a genuine differential, though six weeks of persistent symptoms makes it less likely on its own.
• ECG before any antipsychotic, for QTc.
• Neuroimaging or lumbar puncture if there are focal signs, seizures, headache, fever, catatonia or dyskinesia - consider autoimmune (anti-NMDA receptor) encephalitis, which can look exactly like this. Delirium from an organic cause must be excluded before a functional diagnosis is made.

The statutory test

Under section 2, 'mental disorder' means an abnormal state of mind, continuous or intermittent, characterised by delusions or by disorders of mood, perception, volition or cognition, of such a degree that it poses a serious danger to the health or safety of the person or others, or seriously diminishes the person's capacity to take care of himself or herself. Section 4 excludes political, religious or cultural beliefs held alone, intellectual disability alone, and substance use alone.

Applying it

He has persecutory and grandiose delusions, insomnia and a marked functional decline. He has climbed onto a roof, has not eaten, has lost 7 kg, and has a resting pulse of 112. That combination - serious risk to his own safety plus seriously diminished capacity to care for himself - plausibly meets the criteria. Cannabis use does not disqualify him, and cultural or spiritual framing of his experiences would need to be explored but does not exclude a mental disorder.

The process

• An application under section 8 is made to the District Inspector or duly authorised officer, usually by a family member, the police or a doctor, accompanied by a certificate from a medical practitioner.
• The DAO arranges an assessment examination under section 9 by two health professionals, at least one a psychiatrist where practicable.
• If it appears he has a mental disorder he can be detained for assessment, for a period not exceeding five days (section 11), followed by further assessment, a second opinion and review by the Review Tribunal.

In practice

Call the after-hours psychiatric registrar or crisis team now. Try the least restrictive option first - a voluntary admission brokered with his flatmates and parents present - and use the Act if he continues to refuse and the risk remains. If there is immediate danger, involve the police. Document the reasoning and keep his family informed.

Environment and engagement

Admit to a low-stimulus unit with a clear observation level. Build an alliance: be honest about why he is there, involve his flatmates and parents, and avoid confrontation about the content of his delusions while not colluding with them. Treat agitation with short-term benzodiazepines or oral olanzapine; use restraint or seclusion only as a last resort, for the shortest time, and documented.

Medication

Start a single second-generation antipsychotic at a low dose and titrate - for example risperidone 1-2 mg or olanzapine 5-10 mg. Avoid polypharmacy and avoid two antipsychotics. Discuss the choice with him and his family using plain language about likely benefit and side effects. If adherence becomes a problem, consider a long-acting injectable later.

Baseline and ongoing monitoring

Weight, waist, blood pressure, fasting glucose or HbA1c, lipids, prolactin if symptomatic, and an ECG for QTc. Monitor for extrapyramidal effects and neuroleptic malignant syndrome. Repeat metabolic monitoring at three months and then at least annually - young people with psychosis die prematurely from cardiovascular disease, and this is where it starts.

Psychosocial and cultural care

Refer to the early intervention in psychosis service, and offer psychoeducation, CBT for psychosis, family intervention, and support with study or work. Offer a Maori mental health service and kaumata support, and hold a whanau hui if he agrees - exploring whether his experiences carry cultural meaning is important, but it does not replace treatment. Respect his autonomy and mana throughout. Arrange a risk management plan, a GP handover, and follow-up within a week of discharge.