Transcript MANAGEMENT of FIRST

MANAGEMENT
of
FIRST-EPISODE PSYCHOSIS
H.Amini M.D.
Roozbeh Hospital
Tehran University of Medical
Sciences
Rationale for Early Intervention
• Primary prevention remains out of reach
• Excellent prospects for early
intervention&secondary prevention
• Early detection of new cases
• Shortening the delays to effective treatment
• “Critical Period” of the first years of illness
Benefits of Early Intervention
& Treatment
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Reduced morbidity
More rapid recover
To prevent treatment resistance
To prevent relapse
Decreased need for hospitalization
Preservation of family&social supports
Preservation of psychosocial skills
Better prognosis
Consequences of Delayed
Treatment
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Slower & less complete recovery
Poorer prognosis
Increased risk of depression & suicide
Interference with psychological & social development
Strain on relationships
Loss of family & social supports
Disruption of study & employment
Substance misuse
Violence/Criminal activities
Unnecessary hospitalization
Loss of self esteem
Increased cost of management
Principles for Best-Practice
Management
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Early case detection
A specific focus on therapeutic engagement
A comprehensive assessment
An embracing of diagnostic uncertainty
Treatment in the least restrictive setting
Strategy for Early Detection
• The Duration of Untreated Psychosis(DUP) is an
important indicator
• Unlike other prognostic variables,DUP is
potentially malleable
• Improve recognition: education,reduce stigma
• Increase refferals: a responsive,user friendly
service,reduce stigma & fear
• Provide easy access to services
Focus on Therapeutic
Engagement
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An independent predictor of treatment retention rates
The first experience
The patient may be nervous,wary,…
Be aware that psychosis may distort patients’ mode of
interaction
Listen carefully&take their viewes seriously
Acknowledge&respect the patients’ viewpoint
Be helpful,active & flexible
Carefully explain the procedures
Gather information at the same time
Assessment
• Should be comprehensive
• Consider stress-vulnerability model
• Risk assessment: suicide,self-harm,selfneglect,violence,victimization by others,non-adherence,substance
misuse,…
• Understanding the range of patients’reactions to
psychosis
• Understanding the impact of psychosis on the
lives of patients & families
Embracing Diagnostic
Uncertainty
• Referring agents must feel free to refer clients for
expert assessment on the basis of a suspicion
rather than a certainty
• Early definit Dx may be unreliable or harmful
• Dx of psychosis,rather than the assignment of a
precise DSM or ICD Dx, is an appropriate initial
target
• Provided that organic causes are excluded,a
symptom-based approach to treatment has been
advocated
Treatment Setting
• High levels of symptoms of PTSD
following hospitalisation for an acute
psychotic episode
• To reduce the trauma for clients of an inpatient admission for FEP
• Home-based treatment , a viable alternative
to hospitalisation
• Treatment in the least restrictive setting
Medication Use in FEP
General Management Principles
• Antipsychotic drugs(APs) are the
cornerstone of treatment for the majority of
patients
• Often requires a team approach
• Treatment of comorbid physical&mental
disorders
• Psychoeducation
Medication Use in FEP
General Management Principles …
• To be used in acute & maintenance phases
• Should include low-dose,preferably atypical
Aps
Goales of Medication Use in FEP
• To maximize the therapeutic benefit whilst
minimising side effects
• To ensure the experience is as positive as
possible
• To consider issues of long-term compliance
& respecting the client’s legitimate
aspirations of autonomy
Guidelines for Medication Use
in FEP
• If possible employ a neuroleptic free
observation period of 48 hrs:
• Dx can be confirmed& GMCs excluded
• Possibly only chance to observe patient without
medications
• Particularly helpful in presence of heavy substance use
• BZDs can be used for sedation
Guidelines …
• Low dose atypical Aps are first line
treatments:
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Most evidence with risperidone & olanzapine
Better tolerated
Associated with less: EPSEs,TD?, cognitive impairment
More effective for : negative, cognitive, & affective ?
Symptoms
• Improved neurophysiological profile
Guidelines …
• Advantages of typical Aps :
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Familiar
Effective for positive symptoms
Inexpensive
Available in many formulations
Guidelines …
• Oral route is preferred in both acute &
maintenance phases
• Depot medication should only be used after
oral meds,psychoeducation & compliance
therapies have been trialed