First-episode psychosisAPT (2001), vol. 7, p. 133 - PDF document

First-episode psychosisAPT (2001), vol. 7, p. 133 Advances in Psychiatric Treatment (2001), vol. 7, pp. 133–142Over recent years early intervention in psychosisMost influential was Wyatt’s (1991) review of 22At the same time, evidence was emerging that theepisode of psychosis (Yung Scandinavia. In the UK, the National Serviceof prompt assessment of young people at the firstepisode psychosis are detailed in Box 1. In this paper, Elizabeth Spencer, Max Birchwood & Dermot McGovern Box 1Aims in the management of first-To reduce the time between onset of psychoticTo accelerate remission through effectiveTo reduce the individual’s adverse reactionsTo prevent relapse and treatment resistance NHS Trust. She has a clinical interest in the early treatment of young people with psychosis.Max Birchwood is Director of theEarly Intervention Service (Harry Watton House, 97 Church Lane, Aston, Birmingham B6 5UG) and Director of Research andDevelopment of Northern Birmingham Mental Health NHS Trust. He is also a research professor at the School of Psychology,University of Birmingham. Dermot McGovern is a consultant psychiatrist working in Northern Birmingham Mental HealthNHS Trust. He has a clinical interest in working with people with serious mental illness. APT (2001), vol. 7, p. 134Spencer et al/Lewis & Drake The Birmingham Early This service takes clients aged between 16 and 35Mental Health Trust and it provides clients with ofAt the core of the service is an assertive outreachwith a youth housing agency, also operates acommunity-based respite unit. Within this contextprotocol-based pharmacotherapy, family work,social recovery, work and training schemes andcognitive therapy. Best-practice management The principles detailed in Box 2 are drawn from theguidelines for use in the West Midlands, prepared et alsecondary care is of particular interest. However,practitioners (GPs) have a low index of suspicion ofMcGorry, 1995).A number of strategies have been used to strengthendevelopment of shared care. These could become Box 2Principles for best-practice manage-Treatment in the least restrictive setting using First-episode psychosisAPT (2001), vol. 7, p. 135service also maintains good relationships with thelocal police and has conducted some training withthem in the recognition of psychosis. Regular auditsof pathways to care are conducted. and functional outcomes in psychosis. However, itparticular, young people doubt the usefulness ofform barriers to self-referral (Lincoln & McGorry, is considerable. However, thismental health services are more likely to behowever, agree that it is fostered by a search forcommon ground with the client, an avoidance of adisorder, may be helpful. Studies of substancefrequent client contact with a single worker, can alsorelationship with a mental health worker, a singleservices for early intervention must also be clients and in the interventions offered they shouldof young people concerning work and autonomy.ture for workers, and different aspects of the modelrelationship and for persistent follow-up of individ-breaks owing to holidays and so on. The use of exten-hours if necessary. Workers attempt to engage thes self-perceived needs,ity of services within the team gives continuity, whichenhances engagement. The team is involved withemploys former service users, to whom clients mayment, social recovery group. There is a staff relatives and friends are welcomed as players or The stressvulnerability model conceptualises the However, assessment is not considered completeuntil information is obtained about the clientcurrent and levels of occupationalfamily, and the quality of family relationship is (McGorry, 1995).the above practice. We have observed that clients and we focus psychoeducationTreatment in the least restrictive (1991) found high levels of symptomsfor family members, others have found treatment attwice daily. The success of home-based treatmentdepended not on the degree of initial psychopathol-ogy, but on the degree of family support available toThe aim of pharmacotherapy in first-episode psy-chosis should be to maximise the therapeutic benefitare listed in Box 3 and discussed in detail below. Box 3Recommendations for pharmaco-1An antipsychotic-free observation period2A low threshold for the use of atypicalantipsychotic medications3The use of low-dose antipsychotics plus4The aim of remission5Early assessment of treatment resistance6Maintenance of medication for at least 1 1.If possible, have an antipsychotic-free obser-2.At present, there is no methodologically soundpopulations. However, they have been repeatedlyfound to cause fewer side-effects (e.g. Emsley, 1999),compliance. Similarly, factors that may increase the3.The positive symptoms of most patients with3mg halo-peridol equivalents daily, but they may take 2advantage in exceeding doses of 6mg haloperidolant side-effects and potential non-compliance.Similarly, 24mg risperidone daily should bein the treatment of hostility, but benzodiazepines4.With sufficiently assertive treatment involvingchanges in antipsychotics as necessary, symptomsaim of treatment.5.Studies have shown that, even with changesunsuspected organic factors, mood disorder, sub-6.It is not clear for how long people with first-years of remission following a first episode of non-affective psychosis. Future guidelines may recom- Focus on pychologicaladjustment and maintenance appraisal of their illness and illness (see Birchwood & Spencer, 1999, for a reviewof the area). We strive for a blame-free acceptance ofof mastery over it. We aim to achieve this through itself (Warner, 1994), and their loss has been linked et alrecovery, with social, cooking and mother and baby Focus on the entire young, many will be living with a family or partner.family interventions in first-episode psychosisremain underresearched (see Birchwood & Spencer,1999, for a review of the area).critical family atmosphere later.s (1985) model. We also facilitatefound that families appreciate a forum in which toseem to benefit more when this is driven by issues Prevention of relapse is sharply predictive of its longer-term course, andlong-term outcome of psychosis, presumably bypsychosis (Wyatt, 1991).We have developed an approach to relapsewarning signs of psychotic relapse and to preparethemes and the use of coping mechanisms, drugmacotherapy. Similarly, the early application of CBTBirchwood & Spencer, 1999, for a review of the area).On the basis of a study of time to recovery, the subservice (the Treatment Resistance Early Assess-ment Team; TREAT), which offers reassessment and hope of improving early and long-term outcome Albiston, D. J., Francey, S. M. & Harrigan, S. M. (1998)British Journal of Psychiatry (suppl. 33), 117Bebbington, P. (2000) Early intervention in psychosis:pharmacotherapeutic strategies. In Psychosis: A Guide to Concepts, Evidence and Interventions184. Chichester: John Wiley & Sons.Bindman, J., Johnson, S., Wright, S., and general practitionersBirchwood, M. & Spencer, E. (1999) Psychotherapies forschizophrenia: a reviewSchizophrenia (eds M. Maj214. Chichester: John Wiley &, Todd, P. & Jackson, C. (1998) Early intervention in (suppl. 33), 53, Fowler, D. & Jackson, C. (2000. Chichester: John Wiley & Sons., Iqbal, Z., Chadwick, P., et al (2000) Cognitive approach British Journal of, Spencer, E. & McGovern, D. (2000) Schizophrenia: earlyAdvances in Psychiatric TreatmentCrow, T. J, MacMillan, J. F., Johnson, A. L., (1986) Theneuroleptic treatment. Department of Health (1999) Edwards, J., Maude, D., McGorry, P. D., (suppl. 33), 107116.Emsley, R. A. (1999) Risperidone in the treatment of first-study. Schizophrenia Bulletin. Archives of General PsychiatryFitzgerald, P. & Kulkarni, J. (1998) Home-oriented (suppl. 33), 39Frank, A. F. & Gunderson, J. G. (1990) The role of theHenggeler, S. W., Pickrel, S. G., Brondino, M. J., multisystemic therapy. Johnstone, E. C., Crow, T. J., Johnson, A. L., (1986) The, 115Lang, F. J., Johnstone, E. C. & Murray, G. D. (1997) Servicegeneral practioner. British Journal of Psychiatry,Larsen, T. K., McGlashan, T. H. & Moe, L. C. (1996) First-Lieberman, J., Jody, D., Geisler, S., (1993) Time courseand biologic correlates of treatment response in first-episode schizophrenia. Archives of General PsychiatryLincoln, C. V. & McGorry, P. D. (1995) Who cares? Pathways, 11661171.McGorry, P. D. (1995) Psychoeducation in first-episodepsychosis: a therapeutic process. , Chanen, A., McCarthy, E., (1991) Posttraumaticet al (1995) The prevalencepreliminary survey. Remington, G., Kapur, S. & Zipursky, R. B. (1998) (suppl. 33), 66Robinson, D., Woerner, M. G., Alvir, J. M., (1999)episode of schizophrenia or schizoaffective disorder.Archives of General PsychiatryScully, P. J., Coakley, G., Kinsella, A., (1997)Psychopathology, executive (frontal) and general cognitiveWarner, R. (1994) Recovery from Schizophrenia: Psychiatric andWyatt, R. J. (1991) Neuroleptics and the natural course ofYung, A. R., Phillips, L. J., McGorry, P. D., (1998)prevention of schizophrenia. (suppl. 33), 14 APT (2001), vol. 7, p. 140Spencer et al/Lewis & Drake 1.The following a first psychoticathe time during which individuals decidebinversely related to the duration of untreatedca period during which relapse is commondassociated with increased risk of suicideea period when it is important to offer2.In the pharmacotherapy of first-episode psychosis:ait is often sufficient to treat with benzodiazepinesbnovel antipsychotics are the first-choice treatmentcin most cases, remission of symptoms can bedsymptoms often remit with low doses of anetreatment can usually be safely stopped 63.Best-practice management of first-episodeaa strategy for the early detection of psychosisbthe early establishment of a definite diagnosiscearly admission and assessment in hospitaldthe maintenance of valued social rolesea strategy for relapse prevention. aFaFaTaFaFbFbFbFbTbTcTcTcFcTcTdTdTdTdFdFeTeTeTeTeT4.Psychological adjustment following a first-ais usually uncomplicated if psychotic symptomsbis helped by developing a sense of masteryccan be problematic if the individual feels trappeddis nearly always successful if the individualeis helped by learning how to self-manage5.Therapeutic engagement of young people with aaimproves if staff insist that the young personbis helped if staff search for common ground to experiencesccan be helped by an assertive outreach approachdrequires regular out-patient appointmentseis helped by persistent contact with a keyworker.from the hospital to the community. This has now n Lewis is Professor of Adult Psychiatry at the School of Psychiatry and Behavioural Sciences (University of Manchester, detection; early, effective working to normalise experience of psychosis; and relapseoutcome. Average or median DUP in most systematicsuggest, at least for positive symptoms. However, (2000) found the medianadmission patients. The longer the DUP, the more2 months in those with long DUP. In this respect,assessing all new cases of psychosis within 1 day,(details available from S.L. upon request) showed aThe next step is early, effective and acceptablelegitimate strategy, with two caveats. First, there isbasic pharmacology, doses equivalent to as little as2mg haloperidol daily will give 80% dopamine D2about 4mg daily, with only 4 % of patients needingmore than 6mg (details available from S.L. uponobjectively.in accelerating remission from acute symptoms inyears, five out of six will have relapsed. Moreover,individual psychological techniques such asmonitoring of early signs and compliance therapy.still needed to confirm the effectiveness of earlydetection and intervention services. However, the such a service end up feeling further demoralised. Drake, R. J., Haley, C. J., Akhtar, S., (2000) Causes andschizophrenia. British Journal of Psychiatry, , 511Robinson, D., Woerner, M. G., Alvir, J. M. J., (1999)episode of schizophrenia or schizoaffective disorder.Archives of General Psychiatry How to activate yourActivation is the process whereby you identify yourself to the system. You may activate your subscription at any time To activate your individual (Member or non-Member) subscription go to:http://www.rcpsych.org/sub/activate/basic The first step of the activation process requires a customer number. If you are a Member of the Royal College of, you will need to enter your Membership number. 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