“Optimal biological treatment for first episode psychosis has significant differences from the treatment of more established schizophrenia.” Discuss with reference to the relevant research findings.
Early treatment of first episode psychosis is of crucial importance in the improvement of the prognosis of the illness. When ensuring successful care, timely maintenance of treatment response is optimal in regards to better long term outcomes. The appropriate use of psychotherapeutic drugs to suit each individual can be a difficult task as the side effects of the medication can impact on adherence to treatment. Psycho-education in regard to illness and medication……… The treatment of more established schizophrenia has significant differences compared to first episode psychosis. Treatment options and medications can differ as can dosages of antipsychotic medication.
The aim of this essay is to discuss the differences between treatment of first episode psychosis and more established schizophrenia.
The average age for onset of schizophrenia differs between the sexes. The average age for males is between 15 and 25 years with 39% of males having their first episode of psychosis before the age of 19 years. Twenty-three percent of females with schizophrenia have their first episode of psychosis before the age of 19 and the average onset is between 25 and 35 years (Gearing & Charach, 2009). Gearing and Charach (2009) state the primary reason for hospitalisation in psychiatric institutions is for psychotic disorders. The average length of stay for adolescents is between 25 to 45 days.
Perkins, Gu, Boteva and Leiberman (2005) state there are at least two reasons why it is important that the causes and consequences of untreated psychosis is understood. Firstly, the period of untreated psychosis is a potentially variable prognostic aspect, and to be aware of its relation to outcome could guide the way to enhanced therapeutic strategies and public health schemes. Second, an association of period of untreated psychosis to outcome could possibly be a sign of a neurodegenerative process and so have significant implications for understanding the pathophysiology of schizophrenia. On the other hand, the duration of initially untreated psychosis could possibly be associated with the severity of illness and as a result might be a marker rather than a determinant of outcome (Perkins, Gu, Boteva, & Leiberman, 2005).
Gering and Charach (2009) report that early onset of psychotic disorders is connected with intellectual decline reflected in lowered IQ scores and reduced quality of life noticeable by a reduction in employment-related problems, daily functioning, and social deficits. Adolescent onset of psychotic disorders results in poorer outcomes than onset later in life. There has only been a limited amount of controlled studies which have investigated children and adolescents with psychotic disorders, the majority of which have found that full recovery is gained in less than 25% of younger patients (Gearing & Charach, 2009).
The severity of negative symptoms at first treatment contact is associated with a longer duration of untreated psychosis. Longer duration of untreated psychosis is also associated with the response of negative symptoms to treatment. Patients with a shorter duration of untreated psychosis have experienced greater reduction in negative symptoms in studies reviewed by Perkins et al. This may be because negative symptoms have been shown to be less responsive to anti psychotic medication than positive symptoms. The possible responsiveness of negative symptoms to antipsychotic medication may be limited after a long duration of untreated illness (Perkins et al., 2005).
Perkins et al (2005) state the possibility of relapse, even with total recovery from a first psychotic episode, is especially high. Within five years of initial treatment response, more than 90% of these patients will experience a relapse of psychotic symptoms (Perkins et al., 2005).
The major results from a meta-analysis and review by Perkins et al. found that a long-lasting episode of psychosis experienced prior to the commencement of antipsychotic treatment is linked with poorer levels of symptomatic and functional recovery from the first psychotic episode. It was also found that period of initially untreated psychosis is connected with severity of negative symptoms but not with severity of positive symptoms or common psychopathology at the primary clinical evaluation (Perkins et al., 2005).
The decision on which antipsychotic drug to prescribe first for a patient with psychosis can be difficult as there are no clear recommendations that exist for this choice (Johnsen, Kroken, Wentzel-Larsen, & Jorgensen, 2010; Kumra et al., 2007) . Second generation antipsychotic drugs are usually considered first line agents for people with first episode psychosis. This is based on their ability to alleviate not only positive symptoms but also negative symptoms of schizophrenia (Abbasi et al., 2010; Johnsen et al., 2010).
Rosenheck (2008) found little or no advantage for the use of atypical antipsychotics as compared to the older typical antipsychotics, for use with patients suffering chronic schizophrenia. When atypical antipsychotic drugs were compared to typical antipsychotic drugs like intermediate-potency perphenazine or high potency antipsychotics which were used in low doses or used with prophylactic anticholinergics, there were no advantages found (Rosenheck, 2008).
Kumra et al. (2007) state there are concerns about the severity of side effects and the lack of efficacy of first generation antipsychotics (FGAs) for use with children and adolescents with first episode psychosis. This prompted a search to find an agent which was more effective, was tolerated better and had fewer side effects, for use with younger, antipsychotic naïve, patients. Second generation antipsychotics (SGAs) include drugs such as risperidone, olanzepine, quetiapine, ziprasidone and clozapine. These drugs, as a class, have reduced tendency to cause adverse motor side effects and prolactin increase when they are compared to FGAs of similar strength (Kumra et al., 2007). Maguire (2002) states an increase in prolactin levels can result in serious short and long term problems. Short term problems include depression, menstrual irregularities and sexual dysfunction and long term problems include osteoporosis and decreased bone density. These short term problems can be a cause of non-adherence due to the sexual dysfunction and depression. Relapse of psychosis can occur due to non-adherence (Maguire, 2002).
Kumra et al. state other factors such as impaired cognition, other side effects, and lack of insight are all associated with non-adherence among young people with psychosis. Another important determinant of patients and families' attitude toward treatment is the quality of the relationship they have with their clinicians during acute admission of first episode psychosis (Kumra et al, 2007). Non adherence to medications are being acknowledged as the “other” drug problem, as stated by Robinson, Harris, Harrigan, Henry, Farrelly, Prosser, et al. (2010). Non adherence to antipsychotic medication is associated with negative clinical outcomes and occurs in 20-56% of people with a first episode of psychosis (Cassidy, Rabinovitch, Schmitz, Joober, & Malla, 2010). The rising costs associated with non-adherence and subsequent relapse and readmission to hospital extends into tens of billions of dollars annually (Robinson et al., 2010).
A study by Petersen, Jeppersen, Thorup, Abel, Ohlenschaeger, Christensen et al. (2005) compared integrated treatment with standard treatment to find whether there were any positive effects on clinical and social outcomes for patients with first episode psychosis. It was found that the integrated treatment enhanced clinical outcome and compliance to treatment. The integrated treatment was assertive community treatment. The treatment was provided by two multidisciplinary teams and included specific family involvement and social skills training. It was offered to each patient for two years. It also included psycho-educational family treatment for 18 months, in a multi family group with two therapists. This focused on problem solving and development of specific skills designed to help patients and families cope with the illness (Petersen et al., 2005).
Compliance with treatment ought to be associated with lessening in symptoms during the early phase of treatment, and as a result, symptom change offers a construct which can be used to confirm different measures of compliance (Cassidy et al., 2010)