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Chapter: Essentials of Psychiatry: Schizophrenia and Other Psychoses

Schizophrenia: First Episode Schizophrenia

An enormous clinical and research effort is directed internation-ally towards patients in very early stages of their illness and es-pecially during their first psychotic break with a focus on early and effective intervention.

First Episode Schizophrenia

 

An enormous clinical and research effort is directed internation-ally towards patients in very early stages of their illness and es-pecially during their first psychotic break with a focus on early and effective intervention. First episode provides a unique op-portunity to intervene early and effectively and possibly change the course of illness. It is well known that there is a delay of 1 to 2 years on an average between onset of psychosis and start-ing of treatment. This duration of untreated psychosis (DUP) is recognized by many though not all as an important indicator of subsequent clinical outcome. Larsen and colleagues (2000) ex-amined 1-year outcome in 43 first episode patients and at 1-year follow-up 56% were in remission, 26% were still psychotic and 18% suffered multiple relapses. Both longer DUP and poor pre-morbid functioning predicted more negative symptoms and poor global functioning. DUP remained a strong predictor of outcome even after controlling for premorbid functioning. Clinical dete-rioration appears to be correlated with the duration of psychosis and number of episodes of psychosis. The deterioration usually occurs during the first 5 years after onset and then stabilize at a level where they have persistent symptoms and are impaired in their social and vocational function. After that point additional exacerbation may occur but they are not usually associated with further deterioration.

 

Long-term studies of schizophrenia suggest that negative symptoms tend to be less common and less severe in the early stages of the illness but increase in prevalence and severity in the later stages. Positive symptoms such as delusions and hallucina-tions are more common earlier on while thought disorganization, inappropriate affect and motor symptoms occur more commonly in the later stages of illness. A possible decline in the prevalence of the hebephrenic and catatonic subtypes of schizophrenia may be attributed to effective treatment and possible arrest of the pro-gression of illness. Thus with effective treatment, and with long-term compliance it is possible to produce favorable outcomes.

 

Following onset of the illness, patients experience sub-stantial decline in cognitive functions from their premorbid lev-els. However, it is unclear whether, after the first episode, there is further cognitive decline due to the illness. Some studies even suggest a slight and gradual improvement. Increased number of episodes and the longer duration of untreated psychosis are as-sociated with greater cognitive dysfunction.

 

 

Patients with first episode psychosis usually have excel-lent clinical response to antipsychotic treatment early in their course of illness when compared with chronic multi-episode pa-tients. Effective and early intervention does help achieve clinicaremission and good outcome (Lieberman et al., 1993). Some sug-gest that atypical antipsychotic medication should be used pref-erentially in the treatment of first episode patients with psychotic disorders (Lieberman, 1996) as they are a highly treatment respon-sive group, and may be best able to optimize the outcome. In addi-tion, first episode patients are sensitive to side effects, especially extrapyramidal and weight gain side effects. They require lower doses of medication to achieve therapeutic responses. The issue of treatment adherence is of critical importance in first episode patients. Although these patients respond very well with 1 year remission rates of greater than .80%, the 1-year attrition rates are as high as 60%. This important issue undermines management of first episode patients during this critical period of their illness.

 

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