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MANAGEMENT of FIRST-EPISODE PSYCHOSIS H.Amini M.D. Roozbeh Hospital Tehran University of Medical Sciences Rationale for Early Intervention • Primary prevention remains out of reach • Excellent prospects for early intervention&secondary prevention • Early detection of new cases • Shortening the delays to effective treatment • “Critical Period” of the first years of illness Benefits of Early Intervention & Treatment • • • • • • • • Reduced morbidity More rapid recover To prevent treatment resistance To prevent relapse Decreased need for hospitalization Preservation of family&social supports Preservation of psychosocial skills Better prognosis Consequences of Delayed Treatment • • • • • • • • • • • • Slower & less complete recovery Poorer prognosis Increased risk of depression & suicide Interference with psychological & social development Strain on relationships Loss of family & social supports Disruption of study & employment Substance misuse Violence/Criminal activities Unnecessary hospitalization Loss of self esteem Increased cost of management Principles for Best-Practice Management • • • • • Early case detection A specific focus on therapeutic engagement A comprehensive assessment An embracing of diagnostic uncertainty Treatment in the least restrictive setting Strategy for Early Detection • The Duration of Untreated Psychosis(DUP) is an important indicator • Unlike other prognostic variables,DUP is potentially malleable • Improve recognition: education,reduce stigma • Increase refferals: a responsive,user friendly service,reduce stigma & fear • Provide easy access to services Focus on Therapeutic Engagement • • • • • • • • • An independent predictor of treatment retention rates The first experience The patient may be nervous,wary,… Be aware that psychosis may distort patients’ mode of interaction Listen carefully&take their viewes seriously Acknowledge&respect the patients’ viewpoint Be helpful,active & flexible Carefully explain the procedures Gather information at the same time Assessment • Should be comprehensive • Consider stress-vulnerability model • Risk assessment: suicide,self-harm,selfneglect,violence,victimization by others,non-adherence,substance misuse,… • Understanding the range of patients’reactions to psychosis • Understanding the impact of psychosis on the lives of patients & families Embracing Diagnostic Uncertainty • Referring agents must feel free to refer clients for expert assessment on the basis of a suspicion rather than a certainty • Early definit Dx may be unreliable or harmful • Dx of psychosis,rather than the assignment of a precise DSM or ICD Dx, is an appropriate initial target • Provided that organic causes are excluded,a symptom-based approach to treatment has been advocated Treatment Setting • High levels of symptoms of PTSD following hospitalisation for an acute psychotic episode • To reduce the trauma for clients of an inpatient admission for FEP • Home-based treatment , a viable alternative to hospitalisation • Treatment in the least restrictive setting Medication Use in FEP General Management Principles • Antipsychotic drugs(APs) are the cornerstone of treatment for the majority of patients • Often requires a team approach • Treatment of comorbid physical&mental disorders • Psychoeducation Medication Use in FEP General Management Principles … • To be used in acute & maintenance phases • Should include low-dose,preferably atypical Aps Goales of Medication Use in FEP • To maximize the therapeutic benefit whilst minimising side effects • To ensure the experience is as positive as possible • To consider issues of long-term compliance & respecting the client’s legitimate aspirations of autonomy Guidelines for Medication Use in FEP • If possible employ a neuroleptic free observation period of 48 hrs: • Dx can be confirmed& GMCs excluded • Possibly only chance to observe patient without medications • Particularly helpful in presence of heavy substance use • BZDs can be used for sedation Guidelines … • Low dose atypical Aps are first line treatments: • • • • Most evidence with risperidone & olanzapine Better tolerated Associated with less: EPSEs,TD?, cognitive impairment More effective for : negative, cognitive, & affective ? Symptoms • Improved neurophysiological profile Guidelines … • Advantages of typical Aps : • • • • Familiar Effective for positive symptoms Inexpensive Available in many formulations Guidelines … • Oral route is preferred in both acute & maintenance phases • Depot medication should only be used after oral meds,psychoeducation & compliance therapies have been trialed
