Challenges in the management of early psychosis

Abstract

The first 3–5 years of a psychotic illness are regarded as a critical period during which optimal clinical management may improve the long-term prognosis and reduce disability. Based on this premise early intervention (EI) teams have been set up in various countries. They are a routine part of psychiatric services in the UK, where they generally work with patients under the age of 35 years and within 3 years of the onset of a psychotic illness. A key aim of EI services is to reduce the duration of untreated psychosis (DUP). This is the time between the first onset of psychotic symptoms and the commencement of adequate treatment. A long DUP is associated with a worse treatment outcome in terms of symptoms, functioning and quality of life (Marshall et al., 2005). Work in early psychosis presents several challenges and in this editorial we briefly review some of these including stigma, sensitivity to adverse effects of medication, non-adherence, comorbid substance misuse and issues related to intervention in prodromal or pre-psychotic individuals. Psychosis, and especially schizophrenia, is associated with marked stigma which can lead to social exclusion and impaired quality of life (Thornicroft et al., 2009). Stigma can act as a barrier to prevent first-episode patients entering treatment and so contribute to a long DUP (Franz et al., 2010). This appears to be a particular problem in certain ethnic minority groups (Gary, 2005). Work from Norway and Denmark suggests that intensive education campaigns for the general public, schools and General Practitioners can increase the number of individual seeking help from EI services and reduce DUP (Joa et al., 2008). Patients with first-episode psychosis generally respond well to antipsychotic medication, often at lower doses than chronic patients, and rates of remission are high. However, first-episode patients are also more sensitive to many adverse effects of antipsychotic medication including weight gain, hyperprolactinaemia and extrapyramidal symptoms (Haddad et al., 2011; Haddad and Sharma, 2007). Sexual dysfunction and weight gain may be particularly distressing to young people. Adverse effects early in treatment may shape long-term views about medication and have a detrimental influence on medication adherence. The choice of medication should be made jointly by the patient and their psychiatrist. Antipsychotics differ markedly in their adverse effect profiles but their efficacy is similar in schizophrenia, with the exception of clozapine which has superior efficacy in treatmentresistant schizophrenia. Consequently the patient’s views about potential adverse effects are likely to have a major influence on choice of medication. Antipsychotics should be commenced at a relatively low dose due to the sensitivity of first-episode patients to both therapeutic and adverse effects. Systematic screening for adverse effects is important in all patients but especially within this group. Rates of medication non-adherence are high in EI patients, with one study finding that approximately 60% of patients had adherence problems during their first year of treatment (Coldham et al., 2002). Non-adherence is a frequent cause of relapse. In a 5-year observational study of patients with firstepisode psychosis, the rate of relapse was nearly fivefold higher among those who stopped antipsychotic medication compared with those who continued treatment (Robinson et al., 1999). An important way to improve adherence is for the clinician to gain a better understanding of the patient’s beliefs about their illness, the role of medication and any barriers to medication taking. The clinician can then work with the patient to help them understand how medication may help on an individual level. This process should also allow the patient and prescriber to make a joint decision on the choice of medication, so that the balance between the potential advantages and disadvantages of medication is more attractive to the patient. Rates of substance misuse, particularly of alcohol and cannabis, are high in patients seen in EI services (Barnes et al., 2006). Despite initial controversy there is strong evidence that cannabis use, particularly at a young age, is an independent risk factor for the development of psychosis (Semple et al., 2005). Substance misuse is associated with an increased DUP (Thomas and Nandhra, 2009). This may partly reflect a patient perceiving their initial psychotic symptoms as drug induced, rather than representing a psychiatric illness, leading them to delay obtaining medical help. Even when substance