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.
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.
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 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
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
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.
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:
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.
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.
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
- What is psychosis?
- The symptoms of psychosis
- The causes of psychosis
- The different types of psychosis
- Treatments for psychosis
- Family involvement — issues and concerns
- The process of recovery