1. MANAGEMENT of FIRST-EPISODE PSYCHOSIS H.Amini M.D. Roozbeh Hospital Tehran University of Medical Sciences

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. Assessment Should be comprehensive Consider stress-vulnerability model Risk assessment: suicide,self-harm,self- neglect,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

9. 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

10. Treatment Setting High levels of symptoms of PTSD following hospitalisation for an acute psychotic episode To reduce the trauma for clients of an in- patient admission for FEP Home-based treatment, a viable alternative to hospitalisation Treatment in the least restrictive setting

11. 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

12. Medication Use in FEP General Management Principles … To be used in acute & maintenance phases Should include low-dose,preferably atypical Aps

13. 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

14. 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

15. 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

16. Guidelines … Advantages of typical Aps : Familiar Effective for positive symptoms Inexpensive Available in many formulations

17. 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