Supports for Patients After First-Episode Psychosis Should Remain, Evidence Suggests

A psychotic episode doesn’t happen for the first time out of the blue—it can be years in making, with the young adult gradually withdrawing from friends and activities, doing poorly in school, and losing motivation to shower or even leave his room.

By the time the episode happens and a psychiatrist is asked to prescribe medication, “We are getting into the game late,” said Joseph P. McEvoy, MD, a professor at Georgia Regents University, who presented Thursday’s session, “First-Episode Psychosis 2015: Risk, Prodrome, Treatment and Outcome,” at the 28th US Psychiatric and Mental Health Congress, being held in San Diego, California.

Research that began 10 years ago into intervention programs, which seek to identify with those at risk of psychosis or provide social supports for those who have had a first episode, have shifted thinking into what it takes to prevent progression to psychosis or a relapse, McEvoy said. But the findings also show that educating friends family members—and using them as a resource—can pay dividends, especially by getting patients into treatment months earlier, before damage is irreversible.

“Storms of Dopamine.” The challenge of predicting a first-episode psychosis is that some behaviors—like withdrawing from family members or smoking marijuana—are not that atypical for teenagers. While psychosis has genetic components, McEvoy said, there are no biomarkers, such as a blood test, that can warn physicians years ahead of time that trouble is on the way. This makes intervention tricky, because antipsychotic treatments have serious side effects and should not be given without cause.

The onset of psychosis is preceded by the “prodrome,” in which symptoms sharply increase and there is a period of cognitive decline. Much work has been done in the past decade to understand the relationship to dopamine dysregulation; which McEvoy said, “underlies the onset of psychosis.”

“There is a lot of focus on identify folks early who are heading into a psychotic episode,” he said. “The earlier we get them on treatment, the better they will do in the long run.”

Work by McEvoy and others has found that giving patients supplements of polyunsaturated fatty acids can greatly reduce the likelihood that those at high risk of progressing to psychotic disorder will do so; those that do have a first episode will have reduced symptoms and improved functioning.¹

He cautioned about the use of marijuana: “Substance abusers who become psychotic had better brains (than others at risk), but substance abuse shouldered them into the bucket of psychosis.”

Support After a First Episode. The longer a person goes without care, the less physicians can do for them, McEvoy said. And young adults may resist treatment due to the side effects: would you, he asked, want to gain 30 pounds or experience sexual dysfunction?

The best help for young adults who have had an episode, he said, is to reintegrate them with other people with themselves; they want access to what McEvoy called, “the 3 C’s”—a car, a condo, and a cell phone. Instead of spending funds talking to patients about getting a job, he recommends putting resources into supporting them on a job. And, he said, there will never be enough administrative help in a practice, so learn to rely on a patient’s family. “Family members are grossly underutilized. They want to work with you.”

Ten-year data, from studies in 5 countries, are now available on patients who had intense social support after a first episode. In the first 2 to 3 years during the support period, patients functioned far better than those who lacked such help. Then programs ended, and at the 5-year mark, patients who’d had support “looked a little more like” their counterparts who had not received extra help, McEvoy said. By the 10-year mark, they were indistinguishable from the group with usual care.

He showed a slide of an amputee whose prosthetic leg had been taken away. Would anyone expect that person to be able to run?

Mental health providers who are not specifically trained in psychotic disorders may not be prepared to take over these cases, he said. “Psychotic disorders are bad diseases. Cognitive disorders are bad diseases. It actually takes effort, work, time, and a team to keep people doing OK.”

Reference

1. Amminger GP, Schafer MR, Papageorgiou K. Long-chain omega-3 fatty acids for indicated prevention of psychotic disorders: a randomized, placebo-controlled trial. et al. Arch Gen Psychiatry. 2010;67(2):146-154.