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First Episode Psychosis: An Information Guide Centre for Addiction
and Mental Health

Treatments for Psychosis

First Episode Psychosis: An Information Guide

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Psychosis can be treated, and many people make a good recovery. Research has suggested that the earlier intervention can occur the better the treatment outcome may be. Therefore, it is important to get help as early as possible. However, in the early stages of psychosis, people often do not know what is happening to them, and do not seek treatment right away. Some people may feel there is nothing wrong or that symptoms will go away on their own. Others, if they are aware of the problem, may have concerns about the required treatment.

Assessment

Before a specific treatment is recommended, a thorough assessment is completed by mental health professionals, a group that can include psychiatrists, psychologists, psychiatric nurses, occupational therapists and social workers. Part of the assessment consists of a comprehensive interview with a mental health professional. This will help him or her get a good understanding of the experiences of the person who is experiencing a psychotic episode. Families, partners and/or friends will also be interviewed to get background information that may help with understanding the context of all the symptoms. Blood tests and other investigations, such as brain scans, may be recommended by the psychiatrist to rule out any physical causes of the symptoms.

Diagnosis and treatment

The information gathered from the interviews and investigations will help the team determine the type of psychosis you are experiencing, its possible causes and the best way of helping you. Treatment may be recommended either on an outpatient basis or in hospital. Treatment usually consists of medication and psychosocial interventions.

Medication
Medication is usually essential in the treatment of psychosis. It relieves symptoms of psychosis and plays a critical role in preventing further episodes of illness.

There are many medications available that help relieve the symptoms of psychosis. Medications used to treat the symptoms of psychosis are referred to as antipsychotic medications, sometimes known as neuroleptics. These medications are generally divided into two categories: typical antipsychotics and the newer atypical antipsychotics.

Typical antipsychotic medications that are commonly used include:
chlorpromazine, flupenthixol, fluphenazine, haloperidol, loxapine, perphenazine, pimozide, thioridazine, thiothixene, trifluoperazine and zuclopenthixol.

The newer medications are called atypical antipsychotics and these include: clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel) and risperidone (Risperdal).

Current evidence suggests that all these medications are equally effective in treating a first episode of psychosis. They will differ from one another in terms of their side-effects and, as a result, some medications will be better tolerated by some people and other medications will be better tolerated by others.

Treatment begins with a low dose of medication that is monitored closely for any side-effects. These will usually occur within the first hours, days or weeks of starting treatment. If side-effects develop, the physician may prescribe a lower dose, add a medication to reduce the side-effects, or recommend a different medication altogether.

The details of a specific medication program will be worked out with the physician. If the first antipsychotic medication given does not produce satisfactory results, the person with psychosis will usually be given one or two additional trials of the medications listed above. The goal is to use the least amount of medication possible to relieve symptoms, and to keep side-effects to a minimum. Antipsychotic medications are not usually beneficial right away. It may take days or sometimes a few weeks of treatment to begin to notice improvement.

Many side-effects tend to diminish over time. Some people experience no side-effects.

Though they are annoying, side-effects are usually not serious. Common side-effects include: tiredness, dizziness, weight gain, dry mouth, blurry vision, restlessness, stiffness, constipation and muscle spasms.

Atypical medications as a group are less likely to cause restlessness, stiffness and tremor, but are more likely to cause other side-effects such as weight gain.

People who take antipsychotic medication for many months or years risk developing some involuntary, spontaneous movements of the tongue, lips, jaw or fingers (tardive dyskinesia). “Tardive” means late and “dyskinesia” refers to the kinds of movements that occur. For every year that a person receives antipsychotic medication there is a five per cent chance of developing tardive dyskinesia. This rate adds up over the years of treatment so that after two years the risk is 10 per cent and after five years it is about 25 per cent.

If tardive dyskinesia does develop, there are ways to identify it at an early stage and to modify treatment. This will reduce the risk that tardive dyskinesia will persist or intensify. It is hoped that the atypical antipsychotic medications will be less likely to cause tardive dyskinesia, but as yet this has only been established in the case of clozapine.

Clozapine is a medication that has been proven to be effective for people who do not respond well to standard antipsychotic medications. It is not used as a first-line treatment because it carries some special risks, including possible harm to white blood cells. While these risks are low, people who take clozapine need to have weekly blood tests to check their white blood cell count.

It is important to note that medication must be taken even after the symptoms have been relieved. When medication is discontinued too early, there is a very high risk that symptoms will return. This does not necessarily happen right away, and can happen a number of months after medication is stopped. It will be important to talk with your own doctor to know how long you should remain on medication.

Psychosocial Interventions

Case management
People recovering from a first episode of psychosis often benefit from the services of a case manager or therapist. This person will be a nurse, occupational therapist, psychologist or social worker who has specialized training and experience in psychiatry. A case manager provides emotional support to the person and the family, education about the illness and its management, and practical assistance with day-to-day living. This assistance can help the person re-establish a routine, return to work or school, find suitable housing and obtain financial assistance. Case managers may suggest consultation with other team members for specific concerns. They will also make sure that the different components of the First Episode Psychosis Program are available to clients. They may also recommend programs in the community that contribute to recovery and provide a stepping-stone to longer-term goals involving work or school.

A case manager, or another member of the team with specialized expertise, may provide the following interventions:

Supportive psychotherapy
Going through a first episode of psychosis may leave you feeling very frightened, confused and overwhelmed. Having someone to talk to during the recovery period is an important part of treatment and is critical to the adjustment process. Supportive psychotherapy involves meeting with a case manager or therapist on a regular basis. This support can help you make sense of the illness, address its impact on your self-esteem, and help you to cope and adapt. Supportive psychotherapy aims to help you understand and accept the illness experience and get on with your life.

Group therapy
Groups are an excellent way to help the young person who has experienced a first episode of psychosis to begin to socialize with others. A range of different groups can help with many of the issues and problems that these young people face, such as offering education about the illness, developing an understanding of the impact of the illness, adjusting to the illness and making future plans.

Individual Cognitive Behaviour therapy (CBT)
CBT has been shown to be a useful therapy to help those recovering from a psychosis to work on issues such as understanding the impact of the illness; coping more effectively with stress; to recognize the impact of drugs and alcohol on symptoms; to find alternative, healthy ways to cope with illness; and to reduce symptoms.

Vocational counselling
People dealing with a first episode of psychosis often need help with a wide variety of work and school problems. They may worry about their ability to pursue work or school, or need help with career options. If this is the case, a referral to an occupational therapist can help. Occupational therapy explores objectives and interests. Skill-oriented evaluations are used to identify what peoples’ strengths and challenges are in a work or school setting. To help make a successful transition back to school or work, short-term counselling can be offered and people can be linked to resources in the community.

In First Episode Psychosis: An Information Guide

  1. What is psychosis?
  2. The symptoms of psychosis
  3. The causes of psychosis
  4. The different types of psychosis
  5. Treatments for psychosis
  6. Family involvement — issues and concerns
  7. The process of recovery
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