Recovery in First Episode Psychosis

There are a series of clinics across Canada and internationally whose sole purpose is to treat patients with first episode psychosis. Here in Ottawa, our first episode psychosis program, aka FEPP, is made up of a multidisciplinary team including nurses, social workers, psychiatrists, and other allied health. These clinics were established in recognition of how unique an experience psychosis is and the importance of early intervention. Patients often have positive outcomes when they get good treatment early on, gains that can be lost permanently if they have another episode. And so there is special recognition that intervening at the first episode of a psychotic illness holds the greatest potential for recovery with the hope of improving the overall trajectory of an otherwise debilitating illness.

Most patients who are seen at the FEPP will go on to be diagnosed with schizophrenia or schizoaffective disorder. Other common diagnoses include bipolar disorder or substance-induced psychosis. If a FEPP team does their job well and the patient is consistent with their medications and follow-up, the actual illness can remain uncertain because clear diagnosing can only occur over time and after symptom relapse. The goal in first episode is to prevent this relapse from happening. So in a way, not knowing a definitive diagnosis is a good thing. Unfortunately, patients and family can take this to mean they do not have a chronic illness and to take their mental health care less seriously.

Classically, patients who develop a first episode psychosis are usually male between the ages of 19 and 25. Patients who have a family history of psychosis and are using substances, specifically marijuana, at an early age are also at higher risk. What is tragic is how this illness affects people entering the prime of their lives. It is the life stage where a lot of personal and social growth necessary for adulthood and independence occurs. Psychosis is also a process that is very toxic to the brain and can leave lasting effects. For these reasons, recovering from a psychosis can take months to years.

What is it like to recover from an episode of psychosis?
Generally-speaking, the first couple of months is when medications are started and optimized to stop the active symptoms of psychosis: disorganization in speech and behavior, delusions and hallucinations, also known as positive symptoms. During this time, there is no expectation that the patient can return to work or school as they are experiencing symptoms of the illness, symptoms of recovery and working through the side effects of treatment. Common symptoms that can be part of natural recovery but also side effects to medications include low energy, excessive need for sleep and feeling a tremendous brain fog. There can also be low mood and suicidal thinking as patients grapple with what happened to them and the impact to their lives. More unsettling is how patients can also forget extended periods of their psychotic experience because of how scattered their minds are during the event.

As the psychosis recedes, I have noticed three general patterns of symptoms resolution. The first is that the patient realizes they have distressing psychotic symptoms and start to recognize that they are not reality based. These patients are very relieved to have the symptoms gone and have better outcomes because they are more motivated to stay on treatment. The second, is that the patient does not recognize their psychotic beliefs to be untrue, only that they no longer seem to be relevant anymore. So the voices that tell them they are under investigation stop, and they no longer make the connections they did when they were psychotic that confirmed their beliefs. These patients often can appreciate that their nightmare ended with medication start, but do not necessarily believe the two to be correlated. They also often do not believe then that the situation would happen again if they stopped medications. The third pattern is a total unawareness when they are well, that they were ever psychotic. So when confronted with the police and hospital records, even family testimony, they do not believe it happened, or they believe the records are inaccurate. These patients do not believe they have an illness and do not appreciate the role of medications in keeping them well. It is this patient population that is the most difficult to treat and will have the worst mental and physical health outcomes.

Once the positive symptoms have resolved, the next 6 months are focused on functional recovery. This means having the patient re-enter social spaces and take on more responsibility that is closer to their baseline. Ideally FEPPs are staffed with a recreational therapist and occupational therapist for this reason. These 6 months are also a time when we try to differentiate between the cognitive impacts and negative symptoms of the psychosis itself and other possible reversible factors that could be interfering with recovery, like a depression/anxiety disorder or ongoing substance use. Negative symptoms that are part of the psychotic illness include having less motivation, less spontaneity in thought and feeling, and apathy. Cognitive symptoms of psychosis include disruptions to concentration, memory, organizing and learning. Negative and cognitive symptoms are the most difficult to treat and last much longer than the positive symptoms. They can be permanent. A neuropsychologist is helpful here to assess a patient's cognitive functioning so that the FEPP team can advocate for accommodations at school and work. It is recommended that the return to these areas be gradual and part-time to improve chances of success. It is also during this time that applications for other support like financial aid are completed.

After the first year of recovery, FEPP clinicians are now monitoring and finetuning treatment depending on psychiatric symptoms and side effects. A dietician and exercise-based recreational programs may be available to help with medication-related weight gain and metabolic issues. Throughout recovery, support and education are provided to patients and families to help maintain gains and promote stability.

Like any illness, the recovery and outcomes are as varied as the patients themselves. I have been a psychiatrist at the first episode psychosis clinic in Ottawa for close to 10 years now and it is a challenging yet truly inspiring place to work.