Background

Adherence to medication regimes and developing an acceptable quality of life are likely to be hindered by uncomfortable medication side effects (McGorry et. al., 1996; Falloon, 1996). Outcome studies in the service delivery settings (McGorry et. al, 1996), medications trials (McEvoy et al, 1991; McGorry et al. 1997) and neuro-imaging studies have indicated that most people with first-episode psychosis will respond to doses of antipsychotics much lower than those conventionally used.

We believe there is a particularly strong case for using atypical antipsychotics as a first line treatment given their low rates of extrapyramidal side effects, especially in first-episode psychosis clients compared to those with established illnesses (Emsley et al, 1995). Such distressing effects con be crippling and stigmatising to this young client group and may lead to later treatment reluctance and disengagement.



Requirements

1. If possible, the introduction of antipsychotic medication should be delayed for at least two days until the presence of psychosis is confirmed and organic causes are excluded. Provision for adequate support during this time needs to be available.
   
   
2. Ideally a low dose atypical anti-psychotic drug should be started initially, titrating slowly over one to two weeks, depending on side effects. Long acting benzodiazepines, rather than neuroleptics should be used for sedation and containment of disturbed behaviour, during the acute phase.
   
   
3. Regular reviews should be built into the management plan no less frequently than six weekly (more frequently in the initial phase of treatment to help identify lack of treatment response or development of side effects). Since, with sufficiently assertive treatment, psychotic symptoms in the vast majority of clients with first-episode psychosis eventually remit (Lieberman et al, 1993), resolution of positive symptoms rather than adjustment to symptoms should be the goal.
   
   

4. Since most clients with first-episode psychosis who respond to medication do so early (i.e. often within one month but mostly within six months) (Lieberman, et. al. 1993; Syzmanski et. al. 1996), positive symptoms should not be allowed to linger. The presence of more than mild positive symptoms of psychosis after a six week trial of the maximum tolerated dose of neuroleptic should lead to a review of treatment, including a consideration of diagnosis, treatment of comorbidity and a change of medication.

   Assessment of negative symptoms should form a routine part of the clinical assessment. Studies have found little improvement in negative symptoms after six months of therapy (Lieberman et.al. 1993; Syzmanski et. al. 1996). The presence of disabling negative symptoms after this point should prompt a review of treatment, including the use of atypical neuroleptics and intensive psychosocial rehabilitation.

5. The decision to cease medication should, if possible, be planned between client and treatment team and will depend on degree of symptom remission, emerging syndromal diagnosis, comorbid substance misuse and the presence of remediable risk factors for relapse. Medication regimes should be reviewed routinely as part of the regular review process.
   
   
   

Getting it right....

Chris was experiencing passivity ideas and voices for two weeks. He refused hospital admission but accepted a small dose of medication (2mg Haloperidol) provided by his GP and within 10 weeks his symptoms abated.

Where things can go wrong....

Jane grew convinced that her life was in grave threat and at one point threatened her parents whom she believed she could not trust. She was compulsorily detained and believing she was under attack, hit out. She was given 20mg Haloperidol, she was sedated and developed parkinsonian side affects. She responded to treatment but subsequently refused help, fearing a repeat of side effects.

Ask Yourself.....

• As a clinician can you recall your last three young psychotic clients in inpatient care? How many suffered clear and unpleasant side effects? How many began treatment at “fairly high doses”despite being treatment naive? How many had exposure to several anti-psychotic regimes in a short space of time?
  
  
• Was there any opportunity to start low dose treatment before inpatient care occurred? Was there any opportunity to start at low dose on inception, if necessary using anxiolytics to address disturbed behaviours?