To medicate or not to medicate, when diagnosis is in question: decision-making in first episode psychosis.

OBJECTIVE: This paper reports on a brief survey of clinicians' judgements when making treatment decisions in the context of diagnostic uncertainty. Specifically, attitudes and opinions were sought from practising consultant psychiatrists regarding two key areas of clinical decision-making in first episode psychosis (FEP), namely, when to initiate medication and, how long to continue treatment. METHOD: Interviews were conducted with consultant psychiatrists using a combination of structured and semi-structured questions that examined and explored pharmacological treatment decisions in FEP. RESULTS: Twenty-three consultant psychiatrists participated in the interviews. The threshold to initiate pharmacological treatment was lower when a risk to self or others is present, when symptoms are primarily positive, when the patient is in distress, or where there is a family history of mental illness. Atypical antipsychotics are routinely used as front-line medication in FEP and the choice of medication is determined largely by their likely side effect profile. However, the greater the perceived efficacy, the greater the anticipated tolerability burden. The ideal duration of treatment is considered to be 1-2 years in instances of full remission, and 5 years where only a partial response has been achieved or where recovery has not been sustained. CONCLUSIONS: The 'first episode' represents a unique period in the management of psychosis where by definition there is no history of pattern of illness, diagnostic certainty is rare, and the patient usually does not have any prior exposure to medications. Therefore, each management decision needs to be considered following a risk benefit analysis which takes into account the context of the individual.

A randomized controlled trial of cognitive remediation in schizophrenia.

Individuals with schizophrenia have consistently been found to exhibit cognitive deficits, which have been identified as critical mediators of psychosocial functional outcomes. Recent reviews of cognitive remediation (CRT) have concluded that these deficits respond to training. This multi-site community study examined 40 individuals with schizophrenia who underwent cognitive remediation using the Neuropsychological Educational Approach to Remediation(1) (NEAR). Assessments using the same neuropsychological tests and measures of psychosocial outcome were made at four time points: baseline, before start of active intervention, end of active intervention and 4 months after end of active intervention. Dose of antipsychotic medication remained constant throughout the study period. After participating in NEAR, individuals showed significant improvements in verbal and visual memory, sustained attention and executive functioning. This effect persisted 4 months after the treatment ceased. The average effect size was mild to moderate. Social and occupational outcomes also improved from baseline to post-treatment, which persisted 4 months later. Our findings replicate those of previous studies that suggest that NEAR is effective in improving cognition in individuals with schizophrenia in a naturalistic and ecologically valid setting. Further it extends such findings to show a generalisation of effects to social/occupational outcomes and persistence of effects in the short term.

Let's get physical: an audit of medical practice in first episode psychosis.

OBJECTIVES: To assess aspects of medical examination, diagnosis and side-effect monitoring, and to consider the role of routine investigations in this group as recommended by national guidelines. METHOD: A retrospective file audit was performed on young people presenting with first episode psychosis (n = 117) over 12 months of treatment contact. RESULTS: Diagnoses were: first episode psychosis (43%), schizophrenia (16%), drug-induced psychosis (12%), affective psychosis (13%) and brief reactive psychosis (2%). Only four of the 52 (8%) subjects undergoing neuroimaging had any abnormality, with only two of these requiring referral. Three of the 33 (9%) electroencephalograms were obviously abnormal, but without epileptiform activity. There was little documentation of the assessment of involuntary movements (4% of sample) or weight (15% of sample). CONCLUSIONS: The low rates of clinically important abnormal findings in computed tomography/magnetic resonance imaging and electroencephalogram re-open debate about the need for routine neuroimaging and electrophysiology in this population.

Changes in early psychosis service provision: a file audit.

OBJECTIVE: To measure change in services provided to young people with first-episode psychosis following the introduction of specialized early psychosis teams and staff training. METHOD: A standardized tool was developed to audit services provided to young people with first-episode psychosis. The tool initially comprised 27 clinical indicators measuring aspects of optimal care derived from the Australian clinical guidelines for early psychosis. The first 12 months of treatment, as documented in the case records, were audited for all young people receiving their first treatment for psychosis during a 6-month period prior to the introduction of these service developments (n = 47). These subjects were compared with those who received treatment after the implementation of service development strategies (n = 70). A comparison was also made within the second group, between those receiving some treatment from a specialized early psychosis team and those being exclusively treated by other services. RESULTS: Inter-rater reliability was achieved for 24 of the 27 indicators. Improvements were found on 10 indicators which measured psychosocial interventions, prescribing practices, family interventions and continuity of care. There was no significant deterioration on any of the indicators. Clients who attended early psychosis teams were significantly more likely to receive psychoeducation. CONCLUSIONS: The services increased their provision of "guideline concordant" care for early psychosis. The audit proved useful to monitor performance, to demonstrate improvements in care and to identify those areas of service provision and documentation in need of improvement.