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 n n Stabilizes the patient n n Restores a sense of control in the family n n Reduces the possibility of rehospitalization n n Reduces the risk of violent or suicide behaviours n n 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 n n Early antipsychotic treatment (with low doses) results in better therapeutic responce: u u Early responce, less resistance u u Better relational, educational and vocational prospects u u Less residual symptoms u u Less forensic complications n n Psychological and pharmacological interventions can reduce conversion to chronic psychosis

First-episode psychosis: Benefits of early intervention (continued) n n Reduced inpatient care n n Lower cost n n Fewer relapses n n Less rehospitalizations n n Less family distress - lower expressed emotion n n Better attitude towards treatment n n Better compliance

Main factors related to the delay in the fisrt patient’s contact with mental health services n n Lack of knowledge n n Lack of insight (patient and/or family) n n Fears and prejudices about mental illness n n Stigmatization

Differential diagnosis of first-episode psychosis: Neurological disorders n n Head trauma n n Central nervous system infections n n Brain tumors n n Epilepsy (temporal lobe) n n Multiple sclerosis n n Huntington’s disease n n Wilson’s disease n n Neurosyphilis

Differential diagnosis of first-episode psychosis: General medical disorders   Endocrinopathies (thyroid, adrenal)   Autoimmune disorders (e.g. systemic lupus erythematosus)   Vitamin deficiencies (B 12 )   Hepatic disorders   Metabolic disorders (folate deficiency, porphyria, chronic hypoglycemia, e.t.c.)

Differential diagnosis of first-episode psychosis: Medication-induced psychotic symptoms n n Steroids n n L-Dopa n n Anticholinergics n n H 2 blockers

Differential diagnosis of first-episode psychosis: Psychiatric disorders n n Schizophrenia n n Schizophreniform disorder n n Brief psychotic disorder n n Psychotic mania n n Substance-induced psychosis n n Schizoaffective psychosis n n Major depression with psychotic features n n Psychosis secondary to medical condition n n Psychosis with secondary gain

First-episode psychosis: Investigations n n Blood count n n Electrolytes n n Creatinine n n Glucose n n liver function tests n n Urinalysis n n Toxicology screen n n EEG n n ECG n n CT or MRI

Relapse rates after first-episode of psychosis 82% 5 yearsRobinson, %3.5 yearsKane, %3 yearsRajkumar, % 1.5 yearsZhang, % 1 yearRabin, 1986 Relapse Follow-upAuthor

First-episode psychosis: The critical period n n The “critical” period: covers the period following recovery from a first-episode of psychosis and extends for up to 5 years subsequently n n Up to 80% of patients relapsing within this period (5 years) n n Drug therapy should be continued for most (if not all) patients for 2-5 years

First-episode psychosis: Drug-treatment recommendations n n Careful drug selection and use incorporating lowest effective (and optimized) dose n n Consider risk/benefit for individual patient n n Choice of drug is important particularly if risk factors present

Main guidelines for drug-treatment of first-episode psychosis (NICE, 2002) n n Atypical drugs should be considered in the choice of first-line treatments n n Where more than one atypical is appropriate, the drug with the lowest purchase cost should be prescribed n n 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) n n Patients unresponsive to two different antipsychotics (one an atypical) should be given clozapine n n 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 DrugDosage (mg) Clozapine Amisulpride Risperidone 2-4 Olanzapine 5-10 Quetiapine Ziprasidone Zotepine100 Kane, 2000 n “Low and slow” titration procedure n Addition 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