First-episode Psychosis

Background

• First-episode psychosis (also called early psychosis) is a person's first experience of psychotic symptoms (such as delusions, hallucinations, disorganized thoughts or behaviors, decreased motivation or enjoyment, social withdrawal, or neurocognitive impairments); presentation may range from minor functional impairment without full manifestation to psychotic symptoms attenuated only with intervention.
• Onset of first-episode psychosis is typically in late adolescence or young adulthood, and one-third of cases are diagnosed in acute care settings.

Evaluation

• Evaluate patients with hallucinations, delusions, disorganized speech or behavior, or other psychotic symptoms to exclude alternative causes including substance use, other psychotic disorders, and medical and neurologic conditions.
• Take detailed history and perform general physical and neurologic exam.
• Consider testing as needed to rule out other causes of psychosis, including:
  • blood tests if there is a clinical suspicion of specific nutritional deficiencies, metabolic dysfunction, inflammatory diseases, or infection
  • urine drug screen to exclude causes due to medications and substances
  • pregnancy test (in those of child-bearing age)
  • neuroimaging, if history or exam is suggestive of a neurologic condition
  • if clinically indicated, other testing may include chest x-ray, electroencephalogram, lumbar puncture, microarray and karyotype testing, heavy metal testing, eye exam, and urine studies

Management

• Management of first-episode psychosis is extrapolated from treatment for first-episode schizophrenia, with additional considerations based on clinical presentation (including risk, symptoms, and level of recovery) represented in a proposed clinical staging model.
• For initial management of acute phase first-episode psychosis, (also known as stage 2), treat any medical causes of psychosis and consider:
  • second-generation antipsychotics and other medications, including long-acting injectable antipsychotics to decrease risk of nonadherence
  • multicomponent psychosocial interventions that include psychoeducation, psychotherapies, community care, family interventions, and vocational and substance-related education and support
• For long-term management following an acute phase of first-episode psychosis, consider treatment approaches based on clinical staging model.
  • For patients with stage III first-episode psychosis, treatment options are similar to stage II (acute phase), but with an emphasis on the following:
    • For stage IIIA, consider relapse prevention and early warning signs. However, no interventions have been validated for the tertiary prevention of progression to stage IIIB.
    • For stage IIIB, consider long-term stabilization.
    • For stage IIIC, consider relapse prevention, early warning signs, and treatment resistance. No interventions have been validated for the tertiary prevention of progression to stage IV.
  • For patients with stage IV first-episode psychosis, consider treatment options used for stage III, but with an emphasis on social functioning amid ongoing disability.
• Monitor all patients with first-episode psychosis:
  • Assess for symptoms and early warning signs of relapse.
  • If taking antipsychotic medications, monitor for metabolic adverse effects including acute neurologic effects, such as akathisia and dystonia after starting the medication, and cardiovascular or metabolic effects, such as weight gain with long-term treatment.
  • To track symptoms over time in children and adolescents, consider commonly used symptom rating scales such as the Positive and Negative Syndrome Scale, the Brief Psychiatric Report for Children (BPRS-C), and others.
• Refer patients who engaged in self-injury or injury to others during first-episode psychosis for early intervention. (See Nonsuicidal Self-injury and Suicidal Ideation and Behavior for additional information.)