OPTIMAL TREATMENT INTERVENTIONS

IN RECENT-ONCET PSYCHOSIS

Vassilis P. Kontaxakis

Associate Professor of Psychiatry,

University of Athens

First-episode psychosis: Importance of early symptoms control

Stabilizes the patient Restores a sense of control in the family Reduces the possibility of rehospitalization Reduces the risk of violent or suicide

behaviours Longer duration of pretreatment psychotic

symptoms (duration of untreated psychosis) predicts greater time to remission as well as lesser degree of remission

First-episode psychosis: Benefits of early intervention

Early antipsychotic treatment (with low doses) results in better therapeutic responce: Early responce, less resistance Better relational, educational and vocational

prospects Less residual symptoms Less forensic complications

Psychological and pharmacological interventions can reduce conversion to chronic psychosis

First-episode psychosis: Benefits of early intervention (continued)

Reduced inpatient care Lower cost Fewer relapses Less rehospitalizations Less family distress - lower expressed

emotion Better attitude towards treatment Better compliance

Main factors related to the delay in the fisrt patient’s contact with mental health services

Lack of knowledge Lack of insight (patient and/or family) Fears and prejudices about mental illness Stigmatization

Differential diagnosis of first-episode psychosis:

Neurological disorders Head trauma Central nervous system infections Brain tumors Epilepsy (temporal lobe) Multiple sclerosis Huntington’s disease Wilson’s disease Neurosyphilis

Differential diagnosis of first-episode psychosis: General medical disorders

Endocrinopathies (thyroid, adrenal) Autoimmune disorders (e.g. systemic lupus

erythematosus) Vitamin deficiencies (B12)

Hepatic disorders Metabolic disorders (folate deficiency,

porphyria, chronic hypoglycemia, e.t.c.)

Differential diagnosis of first-episode psychosis:

Medication-induced psychotic symptoms

Steroids

L-Dopa

Anticholinergics

H2 blockers

Differential diagnosis of first-episode psychosis:

Psychiatric disorders Schizophrenia Schizophreniform disorder Brief psychotic disorder Psychotic mania Substance-induced psychosis Schizoaffective psychosis Major depression with psychotic features Psychosis secondary to medical condition Psychosis with secondary gain

First-episode psychosis: Investigations

Blood count Electrolytes Creatinine Glucose liver function tests Urinalysis Toxicology screen EEG ECG CT or MRI

Relapse rates after first-episode of psychosis

82% 5 yearsRobinson, 1999

70%3.5 yearsKane, 1982

55%3 yearsRajkumar, 1982

30% 1.5 yearsZhang, 1994

25% 1 yearRabin, 1986

Relapse Follow-upAuthor

First-episode psychosis: The critical period

The “critical” period: covers the period following recovery from a first-episode of psychosis and extends for up to 5 years subsequently

Up to 80% of patients relapsing within this period (5 years)

Drug therapy should be continued for most (if not all) patients for 2-5 years

First-episode psychosis: Drug-treatment recommendations

Careful drug selection and use incorporating

lowest effective (and optimized) dose

Consider risk/benefit for individual patient

Choice of drug is important particularly if

risk factors present

Main guidelines for drug-treatment of first-episode psychosis (NICE, 2002)

Atypical drugs should be considered in the choice

of first-line treatments

Where more than one atypical is appropriate, the

drug with the lowest purchase cost should be

prescribed

Atypical and typical antipsychotics should not be

prescribed together except during changeover of

medication

Main guidelines for drug-treatment of first-episode psychosis (NICE, 2002) (continued)

Patients unresponsive to two different

antipsychotics (one an atypical) should be given

clozapine

Drug treatment should be considered only part of a

comprehensive package of care

Treatment algorithm for first-episode psychosis (NICE, 2002)

Start atypical antipsychotic

Titrate to minimum effective dose

Adjust dose according to response and tolerability

Effective Assess over 6-8 weeks Not tolerated or poor

compliance

Continue at effective dose Not effective

Change drug and follow above process Change drug Not effective Consider depot Compliance therapy Clozapine

Dosage recommendations for atypical antipsychotic medication in

first-episode psychosis

Drug Dosage (mg)

Clozapine 100-200

Amisulpride 50-300

Risperidone 2-4

Olanzapine 5-10

Quetiapine 200-400

Ziprasidone 40-60

Zotepine 100

Kane, 2000 “Low and slow” titration procedureAddition of benzodiazepines, if necessary

First-episode psychosis: psychosocial approaches

Establish and maintenance of a therapeutic alliance Provide suitable psychoeducation for the patient, the

family and significant others Facilitate adaptation to the psychosocial effects of the

psychotic episode Modify social risk factors Enhance compliance with drug-treatment Promote early recognition of recurrence and

appropriate intervention Reduce the risk of suicide

First-episode psychosis: Conclusions

The management of first-episode psychosis in young patients presents many difficulties including problems in differential diagnosis

Delay in initial treatment is associated with slower and less complete symptoms response

Patients must be quiqly evaluated and drug-treatment as well as patient and family psychoeducation initiated as early as possible