First Episode Psychosis

VICTORIA McALLISTER, Katherine Aitchinson, Patrick Power, Robin Murray, Paola Dazzan, Katherine J. Aitchison, Robin M. Murray, Patrick J. Power, Eva M. Tsapakis, Katherine J. Aitchison, Robin M. Murray, Patrick J. Power, Eva M. Tsapakis

• Publisher: CRC Press
• Year: 2022
• eBook ISBN:
  9780429524141
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

The new edition of this popular handbook has been thoroughly updated to include the latest data concerning treatment of first-episode patients. Drawing from their experience, the authors discuss the presentation and assessment of the first psychotic episode and review the appropriate use of antipsychotic agents and psychosocial approaches in effective management. This is an authoritative text written by a team of highly respected authors for psychiatrists, neurologists, primary care practitioners and health care professional working in psychiatry. Drawing from their experience, the presentation and assessment of the first psychotic episode are discussed, details regarding antipsychotic drugs and their appropriate use are reviewed and psychosocial approaches are examined. The resulting book offers a concise and valuable guide to those wishing to review the latest proposals for the treatment of first-episode psychosis supported by up-to-date references, in a single publication.

1 Why focus on the first episode?

DOI: 10.1201/9780429069956-1

In recent years, increased attention has focused on the first presentation and early course of psychosis. The main reason for this is the realization that treatment is least effective in those patients who have been psychotic for many years. The obvious implication is that closer attention should be paid to patients during the period when the vulnerability to psychosis is first expressed, in the hope that intervention at this point may prevent irreversible neurobiological and social changes.

As early as 1927 Harry Stack Sullivan said of schizophrenia, ‘I feel certain that any incipient cases might be arrested before the efficient contact with reality is completely suspended, and a long stay in institutions made necessary’.¹ Subsequently, Cameron wrote of the value of a preventive approach to schizophrenia, describing the importance of ‘the detection of very early disorder to prevent later serious ill health’.² Such views have been echoed by many recent authorities who believe that early diagnosis and treatment may minimize or even prevent the

Table 1
Treatment lag in studies of first-episode schizophrenia.

Study	Setting	n	Definition	Treatment lag
Beiser et al^7	Vancouver	72	DSM-III	56 weeks
Birchwood et al^10	Birmingham	128	ICD-9	30 weeks
Johnstone et al^6	London	253	ICD-9	28% < 8 weeks
				26% > 52 weeks
Loebel et al^5	New York	70	RDC	52 weeks
McGorry & Singh^11	Melbourne	60	DSM-III-R	74 weeks
From Birchwood et al.^10

devastating psychological and social disturbances that result from continued florid psychosis.^3,4

The importance of early treatment

Much evidence suggests that most patients who present to psychiatrists with their first episode of psychosis have, in fact, been ill for a considerable period (Table 1). For instance, one group in New York found that their patients had suffered psychotic symptoms for an average of 1 year before treatment started.⁵ Other research groups in the UK,⁶ Canada,⁷ Australia⁸ and Germany⁹ have reported a similarly long interval between the onset of psychotic symptoms and the initiation of appropriate treatment. In the Northwick Park study,⁶ the delay before treatment started was longer than 1 year in about a quarter of patients with their first episode of schizophrenia. Furthermore, delay was associated with increasing complications such as severe behavioural disturbance, family difficulties and life-threatening behaviour. The New York group also described an increased risk of life-threatening crises, due either to aggression or suicidal behaviour;⁵ substance abuse, either as a cause or an attempt to self medicate, may further complicate the picture. The delay for affective psychosis may be shorter than for schizophrenia,⁷ though the evidence is conflicting.

Such delays bring obvious distress to patients and their relatives. The patient is usually frightened and may feel extremely isolated from family and friends. When, as is commonly the case, the first episode occurs in adolescence or early adulthood the result can be particularly disruptive. Potentially even more important, however, is the question of whether delay before treatment with antipsychotics actually worsens the long-term outcome. Many psychiatrists believe that the severity of psychotic illness has attenuated over the twentieth century, and that fewer patients have deteriorated to a chronic incapacitated state since the introduction of antipsychotics.¹² Although it is impossible to single out antipsychotics as the sole cause of this change, the temporal relationship is suggestive.

The Northwick Park study reported that those patients taking longer than 1 year to access services (a quarter of their sample) showed a three-fold increase in relapse rate over the following 2 years, compared with those with a briefer duration of untreated psychosis.⁶ Untreated illness emerged as the strongest predictor of relapse irrespective of the use of maintenance medication. The New York group also noted that those patients who had had positive psychotic symptoms for long periods without antipsychotic medication had a slower and less complete recovery, and increased subsequent risk of relapse, than those who received prompt treatment.⁵ It is difficult to exclude the possibility that the former group had a more insidious onset than the latter and, of course, it is well known that patients with an insidious onset fare worse.

Nevertheless Wyatt, who reviewed the literature,¹³ concluded that delay in treating psychosis might indeed worsen the long-term outcome; he went on to suggest that untreated psychosis is biologically toxic and contributes to long-term morbidity.¹⁴ Thus, while the evidence to date does not conclusively demonstrate that early intervention with antipsychotics can alter the natural history of psychosis, many clinicians believe that it is only fair to give patients the benefit of the doubt.

Early detection and referral

One of the barriers to early treatment is that relatives often fail to realize that the sufferer is ill, attributing the changed behaviour to, for example, adolescent problems or to the stress of college or work. Unusual or even bizarre behaviour in adolescents is less likely to attract attention or cause comment than in other age groups, and this may further exacerbate treatment delay. Relatives may also deny the seriousness of the behaviour through fear of mental illness and its stigma. Even when families recognize the illness, their difficulties may be only just beginning; the Northwick Park group reported that patients and their relatives often had made many contacts with services before receiving appropriate help!⁶

Since general practitioners are most frequently the first point of contact for patients and their families¹⁵ it is vital that those in primary care can recognize the early symptoms of psychosis. Social services and, perhaps surprisingly, the police may also be very helpful to families in getting treatment,¹⁶ and deserve to be included in any educational campaign about psychosis.

Thus, factors that can lead to treatment delays include:

• fears about the consequences of having a mental disorder
• difficulties in gaining access to mental health services
• poor screening by primary care health professionals
• inexact diagnosis by mental health professionals

General practitioners, or others who make first contact, need to have access to a psychiatric service to which they can confidently refer those they suspect of having a first episode of psychosis, in the knowledge that they will receive prompt assessment and appropriate care. While this may seem obvious, many standard psychiatric services are more geared to the ongoing care of chronic relapsing patients than the treatment of the ne...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Acknowledgements
• Dedication
• 1. Why focus on the first episode?
• 2. The presentation and assessment of the first psychotic episode
• 3. Before the onset of frank psychosis
• 4. Antipsychotics; pharmacology
• 5. Prescribing for a first episode of schizophrenia-like psychosis
• 6. Prescribing for a first episode of affective psychosis
• 7. Psychosocial approaches - 1 The acute episode and its aftermath
• 8. Psychosocial approaches - 2 Enhancing recovery and staying well
• References
• Index