First Episode Psychosis / Early Psychosis – Key Principles from the Australian Clinical Guidelines for Early Psychosis

Posted on:December 16, 2020

Last Updated: November 9, 2021

Time to read: 6 minutes

The diagnosis and management of early psychosis can pose specific challenges for clinicians.

The presentation of early psychosis is fluid and can encompass a range of symptoms which makes diagnostic categorisation difficult.

On the one hand, it is important that young adults are not misdiagnosed with psychosis while simultaneously recognising that a missed diagnosis can lead to substantial morbidity.

In this article, we summarise the key principles in the assessment and management of First episode psychosis based on the Australian clinical guidelines for early psychosis.

Some of the key features of early psychosis include:

Psychotic disorders usually emerge during adolescence or early adulthood.

They tend to be characterised initially by impaired social functioning and nonspecific ’neurotic’ symptoms, which are then followed by attenuated or subthreshold forms of psychotic symptoms and which emerge just before the development of frank psychosis.

Psychotic symptoms can be part of the spectrum of normal experiences, with a median prevalence of 5% and incidence of 3% in the general population; between 75% and 90% of psychotic experiences are transitory and disappear with time.

Schizophrenia is the third leading cause of burden and injury in young men aged 15–24 years, and the fifth in young women of the same age.

‘Early psychosis’ refers to the early course of psychotic disorder, and these guidelines specifically refer to the prodrome and the period up to five years from first entry into treatment for a psychotic episode (i.e., first-episode psychosis, or FEP).

ASSESSMENT

As soon as possible or within 48 hours of referral.

Comprehensive biopsychosocial assessment by an acute treating team.

Physical Examination

Metabolic functioning and related lifestyle factors (such as diet and exercise)
Rule out organic factors
Metabolic monitoring

Assessment for comorbid disorders

Substance use (including smoking)
Depressive Disorders
Bipolar Disorder
Anxiety disorders
Trauma-related disorders etc
In atypical neuropsychiatric presentations consider the possibility of autoimmune encephalitis. e.g Anti-NMDA encephalitis

Risk assessment

Assess and document at each visit.
Assessment of depressive symptoms, hopelessness, suicidal intent, the effect of returning insight, and the role of psychotic features on mood.
The suicidal risk may fluctuate. (See red flags for suicide later)
Assess for risk to others, risk of neglect, victimisation and non-adherence to treatment.

DIAGNOSIS

Psychosis refers to symptoms in which there are misinterpretation and misapprehension of the nature of reality:

disturbances in perception (hallucinations).
disturbances of belief and interpretation of the environment (delusions).
disorganised speech patterns (thought disorder).

Read more about the assessment of psychotic symptoms in our article on the mental state examination.

Psychotic symptoms should be distinguished from a psychotic disorder

Diagnostic classification systems (e.g., the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, or DSM-5; International Statistical Classification of Diseases and Related Health Problems, or ICD) generally list specific psychotic disorders rather than psychosis or psychotic disorder more broadly.
Diagnoses of schizophrenia, schizoaffective disorder require both clear symptom profiles, and a specified duration of these symptoms, and therefore requires a longitudinal evaluation to arrive at a definitive diagnosis.

Diagnoses may change:

Making the distinction between diagnostic categories early in the course of psychosis may be difficult.
Initial diagnoses of first episode brief psychotic disorder, unspecified schizophrenia spectrum and other psychotic disorder, substance/medication-induced psychosis, and schizophreniform disorder are likely to change over follow-up periods.

ULTRA-HIGH RISK PHASE - DIAGNOSIS AND MANAGEMENT

The possibility of psychotic disorder should be considered for anyone who is experiencing an unexplained functional decline.

Criteria for Diagnosis

Management of Ultra-High Risk Phase

Assess the patient
Monitor safety regularly (every 2–4 weeks) in a context of ongoing support.
Involve family
CBT is the preferred intervention.
CBT may be beneficial in delaying or preventing the onset of psychosis in Ultra-High Risk (UHR) individuals.
Antipsychotic medications should not normally be prescribed unless at least 1 week of frank positive psychotic symptoms have been sustained.
The exception may be where briefer or milder positive symptoms are directly associated with the risk of self-harm or aggression. E.g. in substance-related psychotic disorder, or when subthreshold positive psychotic symptoms persist in the face of CBT and other psychosocial treatments and are causing distress and or disability.
Omega-3 fatty acids may delay or prevent transitions to psychosis.

ACUTE PHASE MANAGEMENT OF FIRST EPISODE PSYCHOSIS

Second-generation antipsychotics (SGAs) should be used in preference to First Generation Antipsychotics (FGAs).
Side effect profile should guide the choice of SGA.
Potential side effects (including metabolic side effects, weight gain, extrapyramidal motor symptoms, and sexual side effects) should be noted and discussed with young people within a shared decision-making approach, prior to pharmacotherapy commencement, and then monitored, managed and addressed early, with a prevention model if possible (e.g., weight management strategies implemented prior to treatment initiation).

Assessment and management of Extrapyramidal side effects

While there is little evidence to suggest that one SGA is preferable to another in this context, side effect profiles of SGAs vary markedly, and these should be taken into consideration when prescribing antipsychotics to young people.

For example, SGAs with a known propensity to cause weight gain, such as olanzapine should be avoided as first-line pharmacotherapy, while those with the lowest risk of weight gain (e.g., aripiprazole and ziprasidone) should be preferred.

Learn more on the newer agents brexpiprazole and lurasidone which are also considered metabolically friendly.

Affective and non-affective psychosis should be distinguished to enable appropriate treatment (i.e., appropriateness of use of a mood stabiliser).
Pharmacological treatment should proceed with a ‘start low, go slow’ approach.
Long-acting injectable antipsychotic medications may be offered as an alternative to oral medication within a shared decision-making approach in which young people are fully informed about, and collaborate in treatment decisions.
Benzodiazepines may be a useful adjunct in florid psychosis for sedation.

LEAST RESTRICTIVE TREATMENT

People with early psychosis should receive treatment in the least restrictive manner possible.

Whenever possible, the location of the initial assessment should be community-based and at a place that is convenient for the person and their family.

Early Recovery Phase

All young people with early psychosis should be seen at least weekly by a case manager, and at least fortnightly by a doctor, in the early recovery phase.
All families should be seen or contacted at least fortnightly during the early recovery phase.
Early response to antipsychotic medication should be considered as a prognostic sign.
CBT interventions may be indicated in this group, as it may speed up recovery, reduce the period of hospitalisation, enhance short-term adaptation to illness, reduce positive symptoms, and improve personal goal attainment.
The possibility of relapse should be discussed with young people and their families, along with education regarding early warning signs and the development of a ‘relapse action’ plan.
Clozapine should be considered for those who have not responded to adequate trials of two antipsychotic medications, of which one is an SGA. [Read more on implications of the delay in starting clozapine]
After resolution of positive psychotic symptoms, antipsychotic medication may be continued for 12 months or more.
A shared decision-making approach and a comprehensive evaluation of the risks and benefits of ongoing medication in each particular case should inform treatment decisions.

Substance Use

Psychoeducation and CBT may help reduce substance use in those in the pre-onset phase and with FEP.
Treatment of psychosis and comorbid substance use (including tobacco use) should be integrated.

RISK FACTORS OF SUICIDE

Up to 75% of people with FEP who commit suicide do so in the early recovery phase, usually with a few months of being discharged from an inpatient unit.

Periods where suicide risk assessment is particularly indicated

The transition from prodrome to psychosis
An early phase of recovery
Early relapse
During rapid fluctuations of mental state
Before granting hospital leave
On discharge from the service
Following any incident of deliberate self-ham
Following loss events

Intensive treatment should be provided during high-risk phases of illness.

SGAs, especially clozapine, may be useful for suicidality. Clozapine and Suicidality

LONG TERM TRAJECTORY OF FIRST EPISODE PSYCHOSIS

The AESOP-10 which was is a follow-up, at 10 years, of 532 incident cases with a first episode of psychosis in the UK showed: [Morgan et al., 2021]

Remitting-improving (58.5%)
Late decline (5.6%)
Late improvement (5.4%)
Persistent (30.6%).

A persistent trajectory, compared with remitting-improving, was associated with gender (more men), black Caribbean ethnicity, low baseline education and high disadvantage, low premorbid IQ, a baseline diagnosis of non-affective psychosis and long DUP.

KEY SUMMARY POINTS IN FIRST EPISODE PSYCHOSIS (FEP)

Young people with FEP are often antipsychotic-naïve.
A young person’s first experience of antipsychotic medication (response and side effects) will influence their engagement and adherence.
People with FEP often respond to much lower antipsychotic doses than those with established illness.
People with FEP generally show a more rapid improvement in symptoms than people with established schizophrenia.
Positive symptoms in people with FEP are generally responsive to treatment in terms of overall response rate and degree of symptom reduction.
People with FEP and young people may be particularly sensitive to antipsychotic associated extrapyramidal side effects.
People with FEP are more susceptible to antipsychotic-associated weight gain and metabolic side effects than those with more chronic illness, due to their younger age and often being antipsychotic-naïve.