Patients experiencing psychosis for the first time should be routinely given brain scans to rule out underlying physical illnesses, according to psychiatrists.
A review involving more than 1,600 patients with a first episode of psychosis who underwent an MRI brain scan found that about 6% had a scan abnormality that led to a different diagnosis or a change to their clinical care.
Conditions detected by scans included encephalitis, brain tumours, infections, stroke or dementia.
“Patients presenting with psychosis may have another physical illness or condition causing their symptoms that can be identified using MRI scanning,” said Dr Graham Blackman, a psychiatrist and clinical lecturer at the University of Oxford and first author of the research. “The reason this is so important is that in this subset of patients, the cause may be treatable and reversible but the window to treat successfully can be relatively narrow.”
Although it is considered good practice to carry out a brain scan in new patients with psychosis, it is not mandatory. A previous appraisal by the National Institute for Health and Care Excellence (Nice) did not recommend scanning all patients because it was unclear how often clinically relevant brain abnormalities were discovered.
“At the moment often it can be difficult arranging a timely MRI scan because it’s not part of routine care,” Blackman said, adding that he was aware of cases involving patients with brain tumours who had waited months for a diagnostic scan, delaying crucial treatment. “It can have huge implications on likely prognosis.”
Psychosis is an experience rather than a medical diagnosis in itself, and involves losing touch with reality. It can manifest as hallucinations or delusions, such as the belief that people are conspiring to spy on you or cause you harm.
In some cases, an episode can be brought on by a traumatic experience, severe stress, drug use or a side-effect of medication. It can be a one-off experience or, for others, is a long-term mental health condition, such as schizophrenia. Treatment normally involves antipsychotic medicine and talking therapies, which can help people develop coping strategies.
There is emerging evidence for a wider range of underlying causes, requiring different treatments. Recent findings suggest psychosis can be triggered by an autoimmune response in the brain, and Oxford psychiatrists are leading a separate trial of the use of immunotherapy to treat patients with psychosis who test positive for certain antibodies.
Prof Philip McGuire, of the University of Oxford and a senior author of the study, said a review of Nice guidance was now warranted. “We feel that this study addresses a critical knowledge gap in this area by showing that clinically relevant abnormalities occur frequently enough to justify making MRI scanning a routine part of the assessment of people presenting with psychosis for the first time,” he said.
Oxford health NHS trust is evaluating the potential benefits of offering all people with a first episode of psychosis an MRI brain scan as part of their initial clinical assessment.
Prof Eileen Joyce, a psychiatrist and researcher at University College London who was not involved in the latest work, said: “This study is important because the finding of a brain abnormality changed the management of one in 18 patients. In addition, it is increasingly recognised that young patients developing psychosis for the first time, without any other detectable neurological abnormality, may have an underlying and treatable form of brain inflammation (encephalitis). Routine MRI scans could help increase the detection of this abnormality, leading to critical early treatment.”
The paper has been published in the journal JAMA Psychiatry.
