Transcript athens-2005-s2-kontaxakis - World Psychiatric Association

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
 Stabilizes
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
First-episode psychosis:
Benefits of early intervention
 Early antipsychotic treatment (with low
doses) results in better therapeutic responce:
Early
responce, less resistance
Better relational, educational and vocational
prospects
Less residual symptoms
Less forensic complications
 Psychological
and pharmacological
interventions can reduce conversion to
chronic psychosis
First-episode psychosis:
Benefits of early intervention (continued)
 Reduced
inpatient care
 Lower cost
 Fewer relapses
 Less rehospitalizations
 Less family distress - lower expressed
emotion
 Better attitude towards treatment
 Better compliance
Main factors related to the delay
in the fisrt patient’s contact
with mental health services
 Lack
of knowledge
 Lack
of insight (patient and/or family)
 Fears
and prejudices about mental illness
 Stigmatization
Differential diagnosis
of first-episode psychosis:
Neurological disorders
 Head trauma
 Central nervous system infections
 Brain tumors
 Epilepsy (temporal lobe)
 Multiple sclerosis
 Huntington’s disease
 Wilson’s disease
 Neurosyphilis
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
 Brief psychotic disorder
 Psychotic mania
 Substance-induced psychosis
 Schizoaffective psychosis
 Major depression with psychotic features
 Psychosis secondary to medical condition
 Psychosis with secondary gain
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
Follow-up Relapse
Rabin, 1986
1 year
25%
Zhang, 1994
1.5 years
30%
Rajkumar, 1982
3 years
55%
Kane, 1982
3.5 years
70%
Robinson, 1999
5 years
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
 Consider
 Choice
risk/benefit for individual patient
of drug is important particularly if
risk factors present
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
Dosage (mg)
Clozapine
Amisulpride
Risperidone
100-200
50-300
2-4
Olanzapine
Quetiapine
Ziprasidone
Zotepine
5-10
200-400
40-60
100
Kane, 2000
 “Low and slow” titration procedure
Addition of benzodiazepines, if necessary
First-episode psychosis:
psychosocial approaches
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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
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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