A first psychotic episode offers the opportunity to build a therapeutic alliance at a teachable moment—while patients and their families are dealing with a devastating diagnosis. With a proactive approach, you can influence how patients view themselves and their experience, including psychotic illness, your efforts to treat its symptoms, and the costs and benefits of interventions.
Unfortunately, the typical first psychotic episode goes undiagnosed and untreated for 1 to 2 years, which some studies suggest may allow schizophrenia to progress. Although controversial, evidence links a prolonged duration of untreated psychosis to poorer outcome.1 Interventions during a prodromal (ie, pre-psychotic but already symptomatic) phase of schizophrenia also is being investigated, with the goal of attenuating—or perhaps even preventing—progression to frank psychosis.2-6
The implication for clinicians: timely identification and treatment may improve response, reduce relapse rates, and ultimately improve schizophrenic patients’ quality of life.
High rates of response—and relapse
Patients with a first psychotic episode show a higher response rate to antipsychotics—up to 87% within 1 year7 —and are more sensitive to side effects than are multi-episode patients.8 Yet despite their high response rate, new-onset patients often suffer from residual symptoms, even when treated in controlled settings. They also have a high rate of relapse—82% within 5 years.9
The strongest modifiable predictor of relapse is medication non-adherence, which has been shown to increase the risk of relapse five-fold.7 The first treatment experience provides a window of opportunity to help the patient accept taking medications as a normal part of life.
CASE REPORT: A FIRST EPISODE OF PSYCHOSIS
Mr. C, a 19-year-old college student, was brought for psychiatric admission after he told his roommates he was a new messiah who “needed to starve himself during the sunlight to enhance his holiness.” Approximately 7 months earlier he had become socially withdrawn and less able to do his college work. Two months later, he started using cannabis frequently. About 5 weeks prior to admission, he developed paranoid ideas involving his roommates and immersed himself in Eastern religions.
History and work-up. Mr. C was overweight and presented with mild dehydration. He did not report relevant signs of depression or mania and had no history of medical or psychiatric problems. Admission work-up included physical and neurologic exams, head CT, and blood work, which were unremarkable except for a positive cannabis toxicology. Family history was significant for one grandfather with alcohol abuse and one uncle who required psychiatric hospitalization in his 20s and never recovered functionally.
Family concerns. Mr. C’s parents were convinced a new diet was causing his symptoms and demanded that he be admitted to a medical ward. His brother insisted the symptoms were secondary to some “bad weed” and that everything would clear up in a few days. Although a brief medication-free observation period was considered to rule out substance-induced psychosis, the prodromal pattern of functional decline for more than 6 months and the bizarre quality of his delusions led to the diagnosis of a first episode of schizophrenia.
Treatment strategy. The treatment team met with Mr. C and his family to educate them about psychotic illness, the risks and benefits of novel antipsychotics, and the need to begin immediate treatment. With the patient’s and family’s consent, risperidone was initiated at 0.5 mg at bedtime and slowly increased over 1 week to 3 mg/d, with only mild and transient sedation. Within 3 weeks, Mr. C responded robustly and was discharged back to his family. Over the next 7 months, he continued taking risperidone, 3 mg/d, with some residual negative symptoms (social isolation without depression) and full remission of positive symptoms, which enabled him to return to college.
Therapeutic alliance. Your approach is key to building a therapeutic alliance with a person whose reality often is clouded by paranoia and referential thinking. Trust begins with the first clinical contact—during history-taking, ordering of tests, answering questions about the diagnosis, and discussing treatment options. Patients and their families must be informed about:
- target symptoms
- medication side effects
- predictors of response and relapse
- lack of certainty about how or when a patient will respond to any antipsychotic
- and the importance of rapid and uninterrupted treatment.
Supportive therapy. Support groups for the patient and family can help destigmatize the illness and reduce stress. Information about schizophrenia’s nature and course is available from the National Alliance for the Mentally Ill, National Mental Health Association, and other sources (see “Related resources”).10
CBT. Adjunctive cognitive-behavioral therapy (CBT) may speed up acute symptom response,11,12 reduce rates of nonresponse, and shorten hospital stays13 by helping patients deal with uncertainty about outer and inner realities. CBT approaches are understudied but so far have not been found to reduce relapse rates.