first episode

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Why treat people with a first-episode
of psychosis in a specialised manner?

The prospects of short term recovery in this group are good:

With sustained treatment over 80% of individuals achieve remission of symptoms from their first episode of psychosis within 6 months (Libermon et oI, 1993).

As a clinician, how many clients can you recall who were under 25 years old who did not achieve discharge after their first episode?As a clinician, how many clients are in 24 hour nursed care, (under your care), and not yet 25 years old? Most clinicians can recall only a tiny number.

Relapse in the early phase of psychosis is associated with increased probability of further relapse and persisting symptoms (Wiersma et aI, 1998)

This suggests that attention to early relapse prevention or minimisation in this group is vital, particularly as over two thirds of people will relapse within 3 years of first presentation which sets the scene for a future cycle of repeated relapse.

As a clinician, can you think of clients who relapse every two years, or more often? Usually they are young, and clinicians can identify from memory several individuals.

When a decline in functions occurs in psychosis, it does so early in the course of the illness, even during the ‘prodromal’ period, prior to the onset of clear psychotic symptoms. This makes early psychosis a biologically ‘critical period':

Many abnormal biological features usually seen in people with well established schizophrenia can also be seen in a subgroup during their first psychotic episode. Cognitive problems associated with schizophrenia emerge at the onset of psychosis and quickly stabilize (Chatterjee and Liberman, 1999)

The early years of psychotic illness also constitute a psychosocial ‘critical period’.

10 to 15% of people with psychosis commit suicide and the risk of this is greatest early in the illness (two thirds of suicides occur within 5 years). Suicide is preceded by factors such as depression and particularly hopelessness, which are potential targets for psychosocial interventions.

Most clinicians can recall the death by suicide of a young person with psychosis, usually with some shock attached to the event. Only in retrospect is the evidence for demoralisation clear, as often the young person has made a fair recovery from the psychosis.

The early phase is also a critical period for return to stable employment. The longer the delay before resumption of work or continuation of the path to work, the greater the likelihood of long-term difficulty.

Adverse outcomes from psychiatric hospitalisation suggest the need to stream the treatment naïve client into a special environment.

45% of people with first-episode psychosis have been found to hove symptoms similar to Post Traumatic Stress Disorder linked to their illness and its treatment. Early use of the Mental Health Act and high doses of antipsychotics with side effects contribute to this. These factors also increase the risk of long term treatment reluctance and service disengagement.

Alice repeatedly described the onset of her illness, the terrifying nature of her experience, the trauma of admission and assessment by a range of unknown professionals. Despite a good recovery, the fact that these events occurred three years ago, and current excellent engagement in the service, she struggled to come to terms with that first contact, and never a day passed when she did not recall these events.