NEW STRATEGIES IN THE PREVENTION AND TREATMENT OF SCHIZOPHRENIA I

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 the patient  Restores a sense of control in the family  Reduces the possibility of rehospitalization  Reduces the risk of violent or suicide behaviours  Longer duration of pretreatment psychotic symptoms (duration of untreated psychosis) predicts greater time to remission as well as lesser degree of remission  Stabilizes First-episode psychosis: Benefits of early intervention  Early antipsychotic treatment (with low doses) results in better therapeutic responce: responce, less resistance Better relational, educational and vocational prospects Less residual symptoms Less forensic complications Early  Psychological and pharmacological interventions can reduce conversion to chronic psychosis First-episode psychosis: Benefits of early intervention (continued) inpatient care  Lower cost  Fewer relapses  Less rehospitalizations  Less family distress - lower expressed emotion  Better attitude towards treatment  Better compliance  Reduced Main factors related to the delay in the fisrt patient’s contact with mental health services  Lack of knowledge of insight (patient and/or family) and prejudices about mental illness  Lack  Fears  Stigmatization Differential diagnosis of first-episode psychosis: Neurological disorders trauma  Central nervous system infections  Brain tumors  Epilepsy (temporal lobe)  Multiple sclerosis  Huntington’s disease  Wilson’s disease  Neurosyphilis  Head Differential diagnosis of first-episode psychosis: General medical disorders  Endocrinopathies (thyroid, adrenal)  Autoimmune disorders (e.g. systemic lupus erythematosus)  Vitamin deficiencies (B12)  Hepatic disorders  Metabolic disorders (folate deficiency, porphyria, chronic hypoglycemia, e.t.c.) Differential diagnosis of first-episode psychosis: Medication-induced psychotic symptoms  Steroids  L-Dopa  Anticholinergics  H2 blockers Differential diagnosis of first-episode psychosis: Psychiatric disorders  Schizophrenia  Schizophreniform disorder psychotic disorder  Psychotic mania  Substance-induced psychosis  Schizoaffective psychosis  Major depression with psychotic features  Psychosis secondary to medical condition  Psychosis with secondary gain  Brief First-episode psychosis: Investigations  Blood count  Electrolytes  Creatinine  Glucose  liver function tests  Urinalysis  Toxicology screen  EEG  ECG  CT or MRI Relapse rates after first-episode of psychosis Author Rabin, 1986 Zhang, 1994 Rajkumar, 1982 Kane, 1982 Robinson, 1999 Follow-up Relapse 1 year 1.5 years 3 years 3.5 years 5 years 25% 30% 55% 70% 82% First-episode psychosis: The critical period “critical” period: covers the period following recovery from a first-episode of psychosis and extends for up to 5 years subsequently  Up to 80% of patients relapsing within this period (5 years)  Drug therapy should be continued for most (if not all) patients for 2-5 years  The First-episode psychosis: Drug-treatment recommendations  Careful drug selection and use incorporating lowest effective (and optimized) dose risk/benefit for individual patient of drug is important particularly if risk factors present  Consider  Choice Main guidelines for drug-treatment of first-episode psychosis (NICE, 2002)  Atypical drugs should be considered in the choice of first-line treatments  Where more than one atypical is appropriate, the drug with the lowest purchase cost should be prescribed 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) Patients unresponsive to two different antipsychotics (one an atypical) should be given clozapine 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 Not effective Clozapine Change drug Consider depot Compliance therapy Dosage recommendations for atypical antipsychotic medication in first-episode psychosis Drug Clozapine Amisulpride Risperidone Olanzapine Quetiapine Ziprasidone Zotepine Kane, 2000  “Low and slow” titration procedure Addition of benzodiazepines, if necessary Dosage (mg) 100-200 50-300 2-4 5-10 200-400 40-60 100 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 drugtreatment as well as patient and family psychoeducation initiated as early as possible