Current Clinical Guidelines

While this phase of illness remains a research focus and further evidence on appropriate and safe interventions must be developed, patients with this pattern of symptoms and functional impairment may still seek help, especially where proactive first-episode psychosis programmes are available. How should they be treated?

The global aim of treatment in this phase is to reduce the symptoms with which the young person presents when first referred, and, if possible, to prevent these symptoms from worsening and developing into acute psychosis. A stress-vulnerability model of the development of psychosis usefully underpins the treatment approach, incorporating medical and psychological strategies. Treatment options should be discussed with patients and their families and reviewed regularly as mental state changes unfold over the course of treatment, and as new evidence becomes available. The following points are based on a draft set of international clinical practice guidelines for early psychosis [1]:

• While the onset of psychiatric disorders of all types peaks in adolescence and early adult life, the possibility of psychotic disorder should be carefully considered in any young person who is becoming more socially withdrawn, performing more poorly for a sustained period of time at school or at work, or who is becoming more distressed or agitated yet unable to explain why. Assessment and regular monitoring of mental state and safety in a context of ongoing support represent the minimal standard here. This should be carried out in a home, primary care or office-based setting in order to reduce stigma. Current syndromes such as depression, substance abuse and problem areas such as interpersonal, vocational and family stress should be appropriately managed where these are present. This level of care essentially represents good general mental health care for young people.

• Young people meeting specific criteria (ARMS) for UHR have a substantially (up to 30-40%) higher risk of transition to psychosis within 12 months even with good quality psychosocial intervention. They invariably have significant levels of symptoms, moderate levels of disability and distress, and often a significant risk of suicidal behaviour.

• If these young people are actively seeking help for the distress and disability associated with their symptoms, they need to be engaged, and offered regular assessment and support, specific treatment for manifest syndromes such as depression, anxiety or substance abuse, and family education and support. If they are not seeking help, regular contact with family members is an appropriate strategy. Information should be provided in a flexible, careful but clear way about risks for psychosis and other mental disorders as well as about existing syndromes and problems. Nearly always, as help-seekers, usually with subthreshold positive symptoms, they are aware of the risk of worsening of the problem, which is a good way of explaining the psychosis risk. Many will have family members with psychosis. Education must be individually tailored. Once again, such intervention should ideally be carried out in a home, primary care or low-stigma office-based setting. At present there is no general indication for the use of treatments aimed specifically at the reduction of risk of psychosis, such as cognitive therapy for psychosis, atypical antipsychotics or experimental neuroprotective drug strategies. The evidence that such treatments are effective remains preliminary. More data are required on the replicability of initial studies, and the risk/benefit ratio of various interventions.

• More specifically, no antipsychotic medications should be used unless the person meets criteria for a DSM-IV psychotic disorder with a duration of over one week, unless rapid deterioration is occurring, severe suicidal risk is present and antidepressants have proven ineffective (assuming depression is present), or aggression or hostility are increasing and pose a risk to others. In the latter two situations, it is likely that inpatient care and observation will be required. If antipsychotics are considered, atypical medications should be used in low doses and considered as a ''therapeutic trial'' for a time-limited period. If there is benefit and resolution of symptoms on 6-week review, the medication should be continued for a further 6-12 months, after all risks have been explained and understood, and the patient is willing. After this, an effort should be made to withdraw the medication, provided the patient agrees and there has been a complete symptomatic and social recovery. If symptoms return when the medications are withdrawn, the patient may, if he/she elects to do so, recommence the medications, provided the longer-term risks have been clearly explained and understood. If the patient has not responded to one atypical antipsychotic, another may be tried, as long as the above indications still pertain.

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