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Psychosis: new research on early treatment

BY KATHRYN QUINN JOHNSON, MA, DO, AND CHRISTIAN NEAL, MD, MPH

Three out of every 100 people will experience psychosis at some point in their lives. Although the warning signs of this serious mental illness—the most common of which is schizophrenia—are experienced during late adolescence and early adulthood, people often wait months or even years before seeking treatment, leading to a lifetime of disability.

In recent years, there has been a focus on detecting the warning signs of psychosis in their earliest stages and intervening with the goal of preventing the disorder and increasing the chance of recovery.

Although the underlying cause of psychosis is not fully understood, changes in the brain’s development may at first manifest in deterioration in everyday functioning, such as memory issues, social withdrawal, changes in mood and uncharacteristic behaviors.

This so-called “prodromal” period is followed by more acute symptoms that can include disordered thoughts and speech, hallucinations, delusions, and paranoia. Because the earliest stages of psychosis can be difficult to recognize, not only for the person affected, but also for family and friends, it is often not until the “first break” or “first episode” of psychosis that there is contact with a mental health professional. According to the National Institutes of Health, approximately 100,000 adolescents and young adults in the United States experience first-break psychosis every year.

Psychotic disorders are degenerative illnesses, leading to atrophying of the brain (a loss of one percent of brain mass with each psychotic episode). Researchers point out that a lack of access to mental health services and treatment in early psychosis and schizophrenia is associated with slower or less complete recovery as well as increased relapse and poorer outcomes in ensuing years. As the illness becomes more persistent and severe, there are increasing visits to emergency departments and hospitalizations as well as societal effects including loss of relationships, unemployment, interruptions in education and poor management of day-to-day activities.

Research over the past decade has shown that intervention within the first five years of a psychotic event—considered the critical period—helps preserve brain function and can lessen the severity and trajectory of the illness.

Mental health practitioners are now making a concerted effort to educate resident physicians, primary care providers and the public about the importance of early symptom recognition, diagnosis, intervention, and treatment of psychotic illnesses.

Early intervention methods include:

• First break psychosis teams in emergency departments help identify people who are not already undergoing treatment but may be having their first psychotic episode.

• Long-acting injectable antipsychotic medications, which were once reserved as a last resort, are now a first line of defense based on their efficacy and convenience. Although antipsychotic medications may cause metabolic/endocrine/cardiac abnormalities or neurological disorders, data has shown that long-acting injectables result in an overall decrease in side effects, hospitalizations, relapse rates, and overall medical costs.

• First break and early psychosis clinics based on the Assertive Community Treatment (ACT) model offer access to clinical providers with specialized training in first episode psychosis on a consultation or outpatient basis. ACT recipients receive the multidisciplinary, round-the-clock staffing of a psychiatric unit, but within the comfort of their own home and community. ACT team members are trained in the areas of psychiatry, social work, nursing, substance abuse, and vocational rehabilitation. ACT clinics use very low-dose antipsychotics to help prevent treatment resistance and minimize side effects.

In addition to antipsychotics, research supports additional assistance for first break psychosis, including individual or group psychotherapy based on cognitive behavioral therapy principles. Also important are family support, employment/education services to help clients return to work or school, and case management to assist clients with problem solving and coordination of social services.

The new focus on early intervention is already showing results. When intervention and treatment occur during the critical period, 25 percent of those diagnosed with firstbreak psychosis have achieved complete remission without relapse. Although a small percentage of patients may never fully recover, the majority of patients are more able to handle underlying symptoms and challenges and go on to live healthier and more productive lives.

Kathryn Quinn Johnson, MA, DO, and Christian Neal, MD, MPH, are psychiatrists with Centra Medical Group Piedmont Psychiatric Center.

For additional information about Centra Medical Group Piedmont Psychiatric Center, please call 434.200.5999 or visit CentraHealth.com