First Episode Psychosis An Avoidable Crisis

The onset of a first episode of psychosis often represents a crisis, with the patient and family experiencing considerable trauma and multiple losses. In a small number of cases the onset is very acute and a hitherto completely well person descends into a florid phase of illness which can truly be called an ''episode''. Much more commonly, the so-called ''episode'' is largely an artefact of late presentation. The episode or crisis could have been prevented, since the patient presents after a considerable period of significant symptoms and impaired function, plus several attempts by himself or his family to seek help [39,40]. However, as any clinician knows, there are a number of obstacles to the early detection and treatment of first episode cases (Table 2.6). Typically, an additional critical event such as an overdose or aggressive incident will have been necessary for a new patient to gain access to specialist assessment and care. This means that intervention usually needs to occur within a broad framework of crisis intervention.

What is the optimal standard of care following detection and diagnosis? Clinical practice guidelines on the treatment of schizophrenia from the Royal Australian and New Zealand College of Psychiatrists [41] state that comprehensive and sustained intervention should be assured during the early years following diagnosis. The long-term course of illness is strongly influenced by what occurs in this ''critical period'' [8], and patients should not have to prove they are chronically ill before they gain consistent or ''tenured''access to specialist care.

A flexible diagnostic approach by mental health services can assist in optimizing care. It is possible to recognize the syndrome of psychosis and

Table 2.6 Obstacles to the early detection and treatment of early psychosis [42]

• The incidence of a first episode of psychosis is relatively low, making it difficult for primary care clinicians to maintain a high level of vigilance and clinical expertise.

• Patients are often concerned about the consequences of referring themselves to mental health services, and might be unwilling to participate when they are referred by concerned families or carers.

• Clinicians are often faced with a dilemma of when, and how assertively, to intervene. This is a particular problem when young people with prodromal features are suffering considerable distress and disability but do not yet fulfil the criteria for a psychotic illness.

• Even when psychosis is apparent and intervention is clearly warranted, there are often delays. First, there may be reluctance to act on the part of some doctors, due to misplaced therapeutic nihilism, especially if the clinical picture resembles schizophrenia. Second, the health system is usually reactive rather than proactive, and often uses a narrow definition of ''serious mental illness'' based on patients having established disability or immediate risk. In such a system, emerging firstepisode psychosis might not be regarded as ''serious'' enough, or patients might be considered too difficult to engage or not in need of assertive follow-up, despite the serious risks inherent in such an approach.

provide full assessment, appropriate treatment and systematic follow-up for young people, despite inevitable initial uncertainty about the underlying causes (e.g. the role of drugs), the precise diagnostic subtype and the longer-term prognosis. The descriptive diagnosis of schizophrenia in particular was poorly designed for early intervention and should not be the sole focus for service provision around onset and the critical period. Derived within tertiary settings, it is still most useful in those environments, though it clearly can be recognized elsewhere.

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