A tool for early, effective psychosis treatment
CAMH Scientist Dr. Ofer Agid led development of an evidence-based algorithm to treat psychosis
When a person first experiences symptoms of psychosis, the treatment they receive can be critical in their long-term recovery. Psychosis, which is an inability to determine what is real or not, usually emerges in early adulthood.
Currently, the only treatment for psychosis symptoms is antipsychotic medication. But there are a number of challenges related to medication use, including the simple fact that it is hard for anyone to take medications daily. In addition, physicians have to decide which of potentially 60 medications to prescribe, and when to adjust dosing or try a different option. And if a patient stops taking medication and relapses, sometimes a drug that previously worked loses its effectiveness.
To address these challenges, researchers in CAMH’s Schizophrenia Division have developed a detailed treatment algorithm for early-stage psychosis. “Our goal is to optimize treatment for patients with psychosis and schizophrenia spectrum disorder as early as possible,” explains Dr. Ofer Agid, CAMH Clinician Scientist, who led the development of the algorithm.
Dr. Agid explains that schizophrenia is no longer considered to be a “neuro-progressive” disease, a category that includes Alzheimer’s and Parkinson’s diseases. In other words, in the past, it was believed that there was long-term decline in brain functioning in schizophrenia, which led to the symptoms people experience. The reality is more complex. More recently, it’s been considered more a disorder of development that originates in childhood, with symptoms appearing in late adolescence or early adulthood.
Yet although evidence suggests there is no major brain deterioration after a person is diagnosed with schizophrenia, “we see that these patients often do decline over time,” says Dr. Agid. By optimizing treatment early, the researchers hope to avoid a worsening of symptoms and functioning. He also notes that if psychosis symptoms are stabilized, clients can benefit from other treatments, such as talk therapy or rehabilitation activities. These help with other symptoms such as impairments in memory, learning and ability to engage in daily activities.
A guided treatment plan
At the outset, choosing the right medication, timing and dose are important, says Dr. Agid. Based on 16 years of research and tracking patient outcomes, the algorithm provides standardized guidance for physicians to make decisions on questions such as: Is my patient responding well enough? When should I try something else? “We had expert consensus on defining what is an adequate response to treatment, partial remission, remission and relapse,” says Dr. Agid. The result is that the algorithm leads to a greater use of injectable medications and clozapine, based on how patients respond, compared to other first-episode psychosis clinics.
The initial or first-line recommended treatment is from a group of medications known as second-generation antipsychotics, such as risperidone, paliperidone and aripiprazole, among many others. If patients do respond to the recommended medication, the algorithm recommends switching to long-acting injectable medication that could be taken just once or twice a month, or once every 3 months, says Dr. Agid. In CAMH’s clinic, about 30 per cent of patients are receiving medication via an injectable. “This level is about 10 times higher than the rest of North America,” he says. “But we know that long-acting injectable antipsychotics reduce the risk of relapse, so once a patient responds to an oral medication and it is tolerated, we try an injectable version early.”
Another difference is the use of clozapine, which can be effective when people do not respond to other second-generation antipsychotics. In the CAMH clinic, 23 per cent of patients are on clozapine.
About 46 per cent of patients in the clinic are taking oral second-generation antipsychotics, and less than two per cent are on first-generation antipsychotics or multiple medications. This breakdown is based on results from 338 patients who went through the algorithm-based treatment between 2009 and 2014.
“We feel this is the target distribution for an early-intervention schizophrenia clinic,” says Dr. Agid.
There are some clients for whom none of the available options work. The researchers are continuing to study those who don’t respond to any treatment, or who refuse clozapine, as well as genetic testing for medication response.