Treatments for first-episode psychosis

What is first-episode psychosis?
People with a first episode of psychosis experience distressing symptoms such as unusual beliefs or abnormal behaviour (positive symptoms) and/or withdrawal or loss of interest in work or school (negative symptoms). Early intervention programs for schizophrenia and psychosis often combine many elements comprising both pharmaceutical and psychosocial therapies, and may involve enriched therapies that are tailored to an individual’s needs. The conclusions presented here are based on group data, and as such individual treatment programs need to be tailored by trained clinicians. Individual response to treatment can vary in terms of both symptoms and adverse effects.

What is the evidence for treatments for first-episode psychosis?

High quality evidence suggests multi-element first-episode psychosis programs involving both antipsychotic medication and psychosocial treatments may provide a small reduction in the risk of relapse and symptoms after a first episode of psychosis compared to treatment as usual. Moderate quality evidence suggests these programs may also improve social function, quality of life, treatment adherence, and treatment satisfaction. The addition of Cognitive Behavioural Therapy or Relapse Prevention Therapy to these programs does not further reduce the rate of relapse or suicide, but may further improve negative symptoms, social function, and quality of life.

High quality evidence shows second generation antipsychotics may be associated with fewer side effects than first generation antipsychotics in first-episode patients, with no differences in symptoms. Moderate quality evidence suggests olanzapine may result in better clinical improvement and treatment adherence than haloperidol, and olanzapine and risperidone may result in fewer side effects. Chlorpromazine, haloperidol, risperidone, and olanzapine may be more effective than placebo from the first week of treatment, and are most effective in the first two weeks of treatment.

Moderate quality evidence suggests no differences in long-term outcomes when medication is delayed for a short period of time and psychosocial treatments are provided in a research setting when compared to immediate commencement of medication without psychosocial treatment. Moderate to low quality evidence suggests no significant benefit of group therapy over individual therapy for negative symptoms, functioning and quality of life, but some benefit for improving psychotic symptoms, treatment adherence and treatment satisfaction.

Also see the Course and Outcomes topic for first-episode and high risk groups, and the pharmaceutical treatment topic for first-episode psychosis.

April 2016

Treatments for first-episode psychosis

What are the treatments for first-episode psychosis?

People with a first episode of psychosis experience distressing symptoms such as unusual beliefs or abnormal behaviour (positive symptoms) and/or withdrawal or loss of interest in work or school (negative symptoms). Early intervention programs for schizophrenia and psychosis often combine many elements comprising both pharmaceutical and psychosocial therapies, and may involve enriched therapies that are tailored to an individual’s needs. The conclusions presented here are based on group data, and as such individual treatment programs need to be tailored by trained clinicians. Individual response to treatment can vary in terms of both symptoms and adverse effects.

What is the evidence on treatments for first-episode psychosis?

High quality evidence suggests multi-element first-episode psychosis programs involving both antipsychotic medication and psychosocial treatments may provide a small reduction in the risk of relapse and symptoms after a first episode of psychosis compared to treatment as usual. Moderate quality evidence suggests these programs may also improve social function, quality of life, treatment adherence, and treatment satisfaction. The addition of Cognitive Behavioural Therapy or Relapse Prevention Therapy to these programs does not further reduce the rate of relapse or suicide, but may further improve negative symptoms, social function, and quality of life. High quality evidence shows second generation antipsychotics may be associated with fewer side effects than first generation antipsychotics in first-episode patients, with no differences in symptoms.

Moderate quality evidence suggests olanzapine may result in better clinical improvement and treatment adherence than haloperidol, and olanzapine and risperidone may result in fewer side effects. Chlorpromazine, haloperidol, risperidone, and olanzapine may be more effective than placebo from the first week of treatment, and are most effective in the first two weeks of treatment.

Moderate quality evidence suggests no differences in long-term outcomes when medication is delayed for a short period of time and psychosocial treatments are provided in a research setting when compared to immediate commencement of medication without psychosocial treatment. Moderate to low quality evidence suggests no significant benefit of group therapy over individual therapy for negative symptoms, functioning and quality of life, but some benefit for improving psychotic symptoms, treatment adherence and treatment satisfaction.

Also see the Course and Outcomes topics on first-episode psychosis and high risk groups, the duration of untreated psychosis, and psychosocial treatments for first-episode psychosis.

April 2016

Early detection

What is early detection of psychosis?

Early detection refers to the correct identification of individuals who are at high risk of developing schizophrenia, with an emphasis on the development of frank psychosis. Several assessment tools have been constructed to effectively identify such individuals. Sensitivity of an assessment tool refers to the proportion of people who develop psychosis that were previously identified by the assessment tool as being at high risk. Specificity is the proportion of people who do not develop psychosis that were previously identified as not being at high risk. Assessment tools therefore aim to have both high sensitivity and high specificity.

Generally, there are two approaches that dictate the characteristics used as markers for detection.

The ultra-high risk approach focuses on a triad of at-risk mental states defined as:

1. Having a family history of psychosis plus non-specific symptoms and a recent decline in functioning

2. Showing recent onset of attenuated psychotic symptoms with a decline in functioning

3. Symptoms must be brief, intermittent and limited

The other approach is based on Huber’s Basic Symptoms, which focuses on a detailed way of describing subjective disturbances, and may be an earlier indicator of risk than the first approach.

What is the evidence for early detection of psychosis?

Moderate to high quality evidence finds the mean rate of transition to psychosis in those assessed as being at clinical high risk for psychosis is around 16% by 2 years and 29% by 3 years. In people assessed as being at clinical high risk of obsessive-compulsive disorder are at higher risk of psychosis than people assessed as being at clinical high risk of bipolar disorder, which in turn has higher risk of psychosis than people assessed as being at high risk of depression. However, the rate of transition to psychosis are only one third the rate of transition to non-psychotic disorders in people at assessed as being at clinical high risk for non-psychotic disorders.

In children and adolescents assessed as being at clinical high risk of psychosis, transition rates were between 17% and 20% by 1 year follow-up and between 7% and 21% by 2 year follow-up. 36% of children and adolescents recovered from their clinical high risk status by 6-year follow-up, and 40% continued to meet clinical high risk criteria without transition to psychosis.

Studies with older samples reported higher transition rates than studies with younger samples, and more recent publications reported lower transition rates than older publications. Studies using the basic symptoms approach reported higher transition rates than studies using the ultra-high risk approach. Studies of people receiving psychosocial treatments (e.g. cognitive behavioral therapy) reported lower transition rates than studies of people receiving standard care (e.g. case management). Studies of people on antipsychotics also reported lower transition rates than studies of people not on antipsychotics.

Moderate to high quality evidence suggests instruments based on ultra-high risk criteria have good sensitivity and moderate specificity. Moderate to low quality evidence also suggests the BSABS scale, based on basic symptoms approach, has good sensitivity and moderate specificity. This indicates validated instuments are generally good at correctly identifying individuals who do develop psychosis, but not as good at identifying individuals who do not develop psychosis.

Moderate quality evidence suggests the model with the best predictive value (86%) for transition to psychosis was a clinical model including odd beliefs, marked impairment in role functioning, blunted affect, auditory hallucinations, and anhedonia/asociality. A biological model using grey matter volume, and a neurocognitive model using IQ, verbal memory, executive functioning, attention, processing speed, and speech perception, both had positive predictive values of 83%. An environmental model with a positive predictive value of 63% involved urbanicity, social-sexual aspects, and social-personal adjustment. The best combination model had a positive predictive value of 82% and involved disorganised communication, suspiciousness, verbal memory deficit, and decline in social functioning.

 

Also see the treatment topics for first-episode psychosis (pharmaceutical and psychosocial) and for individuals at high-risk of psychosis (pharmaceutical and psychosocial).

 

January 2019

Pathways to care

What are pathways to care? 

The help-seeking efforts made by an individual and their families when symptoms of psychosis are apparent, and the clinical services made available as a result of these efforts, are collectively known as ‘pathways to care’. Pathways to care can also encompass service structures that have not been actively sought by the individual. Understanding pathways to care may improve early intervention strategies and contribute to reducing the duration of untreated psychosis.

What is the evidence for pathways to care?

Moderate to low quality evidence suggest young people have around three contracts before receiving specific services for first-episode psychosis. General practitioners are the most common first contact, followed by psychiatrists or specialised services, emergency or inpatient units, family or friends then social workers. Contacts with counsellors or courts led to longer duration of untreated psychosis, which was shortest following referrals from emergency services or general practitioners. Contact with the criminal justice system, emergency or inpatient units were associated with poor patient experiences, disengagement and high costs, despite sometimes resulting in reduced treatment delays.

Moderate quality evidence suggests having a sense of being different or not normal and characterising this difference negatively leads to fewer pathways to care for people with first-episode psychosis or at-risk mental states. Anticipating and experiencing negative reactions from self or others, employing strategies to avoid these negative reactions (such as nondisclosure of symptoms), lack of awareness and understanding of mental illness, and having a negative opinion of services also impacts on pathways to care. Perceived stigma is associated with more negative help-seeking attitudes towards treatment, and service-related stigma is a reason for opposing psychiatric treatment. Shame is the main reason for nondisclosure of symptoms. Care-givers’ concern that loved ones experiencing first-episode psychosis would be labelled as ‘mad’ was a frequent reason for relatives not contacting psychiatric services.

Black people in the U.K. may be more likely to have had compulsory hospital admissions than white people in the U.K, particularly those of African Caribbean or Black African ethnicity. Black people in the UK are also less likely to be hospitalised on first presentation, or to be referred to specialist services, and police are more likely to have been involved during admission. There may be fewer compulsory admissions for Asians with first-episode psychosis in Canada than for Whites, Blacks or those of other ethnic backgrounds.

 

 

February 2019

First-episode psychosis outcomes

What are outcomes for people with first-episode psychosis or high-risk mental states?

After being identified as having high-risk mental states, or after an initial diagnosis of psychosis, relevant outcomes over the years following include transition to psychosis or schizophrenia, symptom severity, recovery and remission, relapse, employment, functioning, relationships, and quality of life. Investigating these outcomes and the factors influencing them provides insight into early treatment strategies.

What is the evidence for outcomes in people with first-episode psychosis or high-risk mental states?

Moderate quality evidence suggests up to 80% of people have good or intermediate outcomes following a first episode of psychosis (follow-up was for 3 years). Positive outcomes include lack of relapse or rehospitalisation, more employment, more insight and clarity, and improved relationships with family and friends. Predictors of good outcomes include being treated with a combination of pharmacotherapy and psychosocial therapy, and being from a developing rather than a developed country. Predictors of poor outcome include being treatment-naive, or being medicated with first generation rather than second generation antipsychotics.

For people with first-episode psychosis or schizophrenia and a current substance use disorder, moderate to high quality evidence suggests worse positive and depressive symptoms, and worse global functioning compared to people with first-episode psychosis or schizophrenia and a former, or no history of a substance use disorder. Moderate quality evidence also suggests an increased risk of relapse, re-hospitalisation, and treatment non-adherence, particularly if using cocaine, opiates, or ecstasy.

Moderate quality evidence indicates the average risk of transition to full psychotic episode in people at high clinical risk of psychosis is ~24-29%. Studies assessing psychosocial treatments or antipsychotics reported lower transition rates than studies assessing standard care or no antipsychotics. People with brief, limited or intermittent psychotic symptoms have higher transition rates to full psychosis than people with attenuated or milder psychotic symptoms, who in turn have higher transition rates than people with genetic vulnerability and a marked decline in functioning. Neurocognitive deficits, negative and disorganisation subclinical symptoms, but not positive subclinical symptoms, are associated with poor functioning in people with high-risk mental states.

 

Also see the treatment topics for first-episode psychosis (pharmaceutical and psychosocial) and for high-risk groups (pharmaceutical and psychosocial).

February 2019

Duration of untreated psychosis and outcomes

What is duration of untreated psychosis (DUP)?

DUP is generally determined as the time from the onset of psychotic symptoms to the initiation of treatment or first clinical presentation, when a diagnosis of first-episode psychosis may be given. Longer DUP has been associated with poorer prognosis and is thought to be a predictor of the likelihood and extent of recovery. As such, understanding the effects of DUP is particularly important because it is potentially modifiable.

What is the evidence for DUP and outcomes?

Moderate to high quality evidence indicates longer DUP, particularly over 9 months, is associated with more severe symptoms, including symptoms of depression and anxiety, and poor social and overall functioning, quality of life, and low response to treatment. Moderate quality evidence also suggests less likelihood of remission with a longer DUP. Effect sizes were all small to medium-sized.

Moderate quality evidence finds a large effect of increased risk of homicide, and a small effect of increased risk of deliberate self-harm with longer DUP.

Moderate quality evidence finds brain structural anomalies in people with first-episode psychosis are not consistently associated with length of DUP.

 

February 2019

Duration of untreated psychosis

What is the duration of untreated psychosis (DUP)?

DUP is generally determined as the time from the onset of psychotic symptoms to the initiation of treatment or first clinical presentation, when a diagnosis of first-episode psychosis may be given. Longer DUP has been associated with poorer prognosis (see the DUP and outcomes topic). As such, understanding the effects of DUP is particularly important because it is potentially modifiable.

What is the evidence for DUP?

Moderate to high quality evidence indicates the presence of an obligatory dangerousness criterion for compulsory treatment of mental illness is associated with longer DUP.

Moderate quality evidence finds people with schizophrenia or non-affective psychosis have a longer DUP (~28 weeks) than people with affective psychosis, regardless of age or sex. Longer DUP was also found in low-middle income countries than in high income countries, but there are no differences in the length of DUP between Black, Asian or White ethnic groups.

Moderate to low quality evidence indicates emergency services and inpatient units are associated with a shorter DUP than community services pathways to care.

Moderate quality evidence suggests long-term, widespread educational campaigns covering multiple domains such as advertising, distribution of brochures, visits to GPs and schools, training seminars, and follow-up contact may reduce the length of DUP. A one-dimensional campaign approach, such as solely educating GPs, may not be as effective.

Also see the related topics on outcomes of DUP.

 

February 2019