Medication
There is now recognition that the treatment approach required for a young person with a newly diagnosed psychotic illness is in many ways different from the approach which may suit a person with a more long-standing illness. This is particularly so in the area of pharmacological treatment.
People with a first episode of psychosis are often more responsive to lower doses of medication than doses recommended for those with multiple episodes of psychosis. They also tend to be more sensitive to antipsychotic medications and therefore quite susceptible to possible side-effects. The fact that antipsychotic medications take time to work and many side effects are dose- dependent should be considered.
Furthermore, clinicians should also be aware that the young person’s first experience of psychotropic medication will have considerable influence on subsequent engagement and adherence to treatment. Non-adherence to medication is an extremely common and major issue in the treatment of people with a first episode of psychosis (see Coldham E.L, Addington J, Addington D 2002).
The quality of the therapeutic relationship is critical in improving adherence to treatment. A collaborative approach with the young person, in which beliefs and concerns are discussed, is more likely to be successful than mere insistence. Enlisting the support of the family or other carers can also assist initial adherence with some young people.
It is essential to provide information about the prescribed medications to both the young person and his or her family.
If a young person has made a good recovery and chooses to cease their medication, it is important for the clinician to maintain a good relationship that does not cause friction with the young person. In this way, should a relapse occur, the young person may be more likely to trust their clinician, feel they are working together and restart medication if necessary.
Diagnosis of a first psychotic episode can be unstable, so delaying the commencement of antipsychotic medication for up to 48 hours, taking a ‘wait and see’ approach may be warranted. This may allow time to seek clarification regarding alternative diagnoses, such as drug intoxication or drug-induced psychosis. However, this needs to be assessed on an individual basis and be balanced with the consideration that prolonged duration of untreated psychosis can be predictive of decreased efficacy of antipsychotic medication.
For more information and recommended reading on pharmacotherapy in first episode psychosis see Lambert, M (2009) ‘Assessment and pharmacology of the acute phase’ in Jackson H.J. & McGorry P.D. (Eds) The recognition and Management of Early Psychosis: A Preventative Approach.
The following guidelines are suggested for commencing antipsychotic medication:
- A ‘shared decision making’ approach with the young person should be taken in treatment (medication) planning.
- Atypical antipsychotics are preferred due to their greater tolerability.
- Non-affective and affective psychoses require separate approaches to initial pharmacotherapy.
- Start low! Antipsychotic medication takes time to work, and increasing the dose rapidly offers no particular advantages. Therefore the lowest effective dose of antipsychotic medication should used. Lower doses appear to be effective in the first episode.
- Go slow! Small increments to the dosage should be made over appropriate time periods. There is an increased risk of side effects if increments occur too quickly.
- The adjunctive use of a long-acting benzodiazepine over the first few weeks can help control agitation and provide sedation until the anti-psychotic medication starts to have it's full effect.
- Given the high rate of non-adherence, there should be regular monitoring of medication adherence.
- Side effects should be discussed, managed early, and need frequent monitoring. Early detection and treatment adaptation will reduce subjective distress associated with side effects and optimise adherence to medication. Side-effect assessment scales can be a useful tool in this respect (e.g. LUNSERS (Day et al., 1995), and UKU (Lingjarde et al., 1987)).
- Co-morbid psychiatric disorders should be treated as early as possible as these are indicators for a reduced response to antipsychotic medication.
- Clinicians should consider the length of antipsychotic treatment, and may consider prescribing an antipsychotic for at least 12 months following a first episode. Longer periods of treatment should be considered if the client falls into a higher risk of incomplete recovery group or experiences a relapse of their illness. (see Robinson et al., 1999)
- Adapt treatment according to changes in presentation or diagnostic shift e.g. adding mood stabilisers for mania symptoms, choosing medications with less metabolic problems for those at high risk of metabolic side effects and weight gain.
References
Coldham E.L, Addington J, Addington D 2002: Medication adherence of individuals with a first episode psychosis. Acta Psychiatr Scand 106: pp286-290
Day, J. C., Wood, G., Dewey, M. & Bentall, R. (1995). A self rating scale for measuring neuroleptic side effects. Validation in a group of Schizophrenic Patients. British Journal of Psychiatry, 166, 650-653
Lingjaerde O, Ahlfors UG, Bech P, Dencker SJ, Elgen K. 1987. The UKU side effect rating scale. A new comprehensive rating scale for psychotropic drugs and a cross-sectional study of side effects in neuroleptic-treated patients. Acta Psychiatr Scand Suppl.;334:1-100.
Robinson D, Woerner MG, Alvir JMJ, Bilder R, Goldman R, Geisler S, Koreen A, Sheitman B, Chakos M, Mayerhoff D, Lieberman JA 1999: Predictors of relapse following response from a first episode of schizophrenia or schizoaffective disorder. Archives of General Psychiatry Volume: 56 Issue: 3 Pages: 241-247