Treatment considerations in First Episode Psychosis
Below is an example of how a patient's psychosis may present to me at the First Episode Psychosis clinic where I work. In parentheses are some of the specific symptoms that would qualify this patient for a diagnosis of psychosis and a referral to our clinic.
The patient believed the radio station was communicating with him (a delusion of reference) and it was telling him that the female in the car next to him was in danger (auditory hallucinations). He had also believed at this time that he was capable of saving the world (a delusion of grandeur) and so he followed her home believing he was going to save her life. When he got to her house, he began yelling something at her that she could not understand (disorganized speech) and disrobing, even when it was raining out (disorganized behavior). My patient did not remember this behavior, but the young lady was so frightened when he would not leave that she called the police and he was arrested and charged with harassment.
This example highlights how all-consuming psychosis is, how high the stakes can feel to the patient. This case also highlights the unfortunate consequences when psychosis and real life collide. We are currently in the midst of trying to help this patient have the harrassment charges dropped because of how evident it is to us, his treatment team, that he was experiencing a mental illness at the time of his arrest.
The good news, is that antipsychotics are highly effective medications for treating psychotic states. Unlike many other disorders where talk therapy could be tried first, psychosis responds best to medications. The bad news is that medications can carry negative side effects like movement disorders, apathy and cognitive blunting (to name only a few). Though, there are several newer medications available now with far fewer side effects.
Because of how effective medications are in treating psychosis, it is often not the acute stabilization that is complicated, but the more longer-lasting aftermath and recovery afterwards.
Here are some reasons for why this might be in First Episode Psychosis:
1. The average age of most patients with a first episode psychosis is late teens to early 20s. This is such a dynamic time in a person's life where patients are discovering their identities, experimenting, and taking on serious responsibilities, commitments and relationships for the first time. Psychosis completely upends this trajectory, at times, up to 1-2 years or more. In part, this is because psychosis can affect how patients learn, think, and feel. Social interactions can become more overwhelming and are exacerbated by the stigma of having a psychotic illness. This is why at the First Episode Psychosis clinic I work at, we offer recreational therapy involving low-stress social activities. We also have an occupational therapist to help re-integrate our patients back into school and work by setting up the necessary accommodations.
These young people expect to bounce back and recover quickly. It is a huge adjustment of expectation and a huge loss when they realize this is not the case.
2. A clear diagnosis is almost impossible to know after a first episode psychosis. A first episode psychosis clinic is usually mandated to treat primary psychotic illnesses (meaning the psychosis is the illness itself and not thought to arise from another illness or cause), some clinics are less strict because we know how difficult this criteria is to establish. Examples of primary psychotic illnesses would include schizophrenia, schizoaffective disorder, and delusional disorder. Illnesses that when severe can cause psychosis include depression, bipolar disorder and substance intoxication. In these cases, the psychosis is considered secondary.
Further complicating things is that extreme states of many other illnesses can look like psychosis and differentiating between the two is very challenging and time-consuming, in some cases impossible. Examples would include obsessive compulsive disorders, severe personality disorders and severe anxiety states. I have seen psychosis emerge after traumatic experiences and head injuries. Our task is to try to know if one caused the other versus if there are in fact two separate illnesses co-existing in the same individual. What this means is that our clinic receives all the psychiatric presentations that other physicians or mental health clinicians can not explain. I admit I love the detective work that goes into the process of establishing a diagnosis. It can only happen with longer term follow-up and the end result will influence what treatment the patient should be on and more of what can be expected down the road. It is for this reason that in our clinic, we follow patients for up to 3 years.
3. There is some controversy surrounding how long a patient needs to be on treatment. When we do not know if we are dealing with a primary or secondary psychotic illness (which is most of the time), it is hard to give clear direction around treatment duration. Some psychotic states, like a brief psychotic disorder, are not expected to return and so treatment can be quite a short course, similarly with psychotic illnesses related to intoxication states.
It is generally recommended that medications should be continued for 1-2 years after complete recovery, in instances where there is a secondary psychosis or a brief psychosis. If however, we can make a chronic primary psychotic diagnosis like schizophrenia, than these patients need to stay on treatment lifelong to prevent relapse. Evidence has emerged that relapse rates are much higher in patients who stop treatment and that relapses can occur anywhere between 1,3, even 8 years after medication has been stopped.
So the obvious questions arise, with no clear answers: When most of the patients I see don't have a confirmed primary psychotic illness, how long should they stay on treatment?
And what happens when despite our advice, patients wish to stop treatment anyway (which happens very often)?
4. First episode psychosis patients have a high rate of substance abuse. I would say marijuana and alcohol are used most commonly in my experience. The negative impact of recreational drugs is not unique to psychotic illnesses. In every mental health disorder, adding a recreational drug to the mix really muddies the waters. It makes diagnosis much more difficult, but also makes treatment recommendations and response far less effective and reliable. Addictions is a huge issue for everyone working in mental health and even when we can stabilize the psychosis, if there is no addictions support alongside, the prognosis is poor. Unfortunately our clinic does not have specific addictions expertise, though we informally provide it the best we can. We will make the necessary referrals to addictions resources, but in this patient population, being young and lacking insight, engagement in addictions care is very low, even after a psychotic illness and other negative consequences of using substances. This demonstrates how severe of the illness of addictions can be, to cause the larger illness burden than the psychosis itself.
5. Anosognosia: a fancy word for no insight. I have seen this word used most in neurology, and specifically in post-stroke patients. Because depending on how their brain has been affected by the stroke, some patients have no awareness that they have had a stroke and have been impaired. Anosognosia also happens to be a symptom very common in schizophrenia and bipolar disorder.
Because patients do not believe they have a psychotic illness, they do not believe they need to see a psychiatrist, and they do not believe they need medication.
I have seen anosognosia take many forms. Some patients continue to believe the delusions. Even if they are no longer active for them, they believe that the delusions did indeed occur. Some patients remember a time that they were not themselves but do not believe it was due to illness. These patients firmly believe they will not relapse, even when they have relapsed before and these patients will deny the negative consequences are a result of the psychosis (like criminal charges).
Not surprisingly, these patients will often stop treatment and relapse frequently. Unfortunately, in most cases, the anosognosia never goes away and these patients, if they meet the criteria, will find themselves on mandated treatment, either through the courts if they have criminal charges as a result of their psychotic illness or through a community treatment order.
To conclude, psychosis is a very difficult and extraordinary experience to go through. Its effects can be long-lasting and life-changing. But I also need to mention how much I enjoy working with this patient population. Often parents are surprised when their child has started care in our clinic and I tell them, with complete sincerity, what an uplifting and hopeful field of psychiatry this is. That outcomes can be very good. I have seen this first hand after working in the First Episode clinic for many years, and I admit, it still surprises me. Most of these patients are ambitious, caring, resilient, intelligent people. Many describe the path to recovery as a detour and are more motivated than ever after recovery to live their lives to the fullest.