Below, Professor James Scott provides a commentary on some of the salient points from a recent Australian review that highlights the importance of quality prescribing as being critical for optimising recovery in first episode psychosis.1
Early psychosis, or the period within the five years following first-episode psychosis, is often treated with dopamine antagonists or partial agonists (DA/PA). However, uncertainty remains about the appropriate duration of their use in this setting. This review recommends six key principles for early psychosis prescribing.
The importance of initial antipsychotic choice
DAs or PAs are widely used in people with first episode psychosis. Guidelines generally recommend that treatment continues for at least 2 years. Despite this, almost three quarters of people with first episode psychosis will discontinue within 12 months, due to adverse events or lack of efficacy.
Thus, it is very important that the initial antipsychotic choice is based on longer-term use– it is not acceptable to focus on the short-sighted aim of addressing acute symptoms within an acute inpatient setting.
It is very important that the initial antipsychotic choice is based on longer-term use– it is not acceptable to focus on the short-sighted aim of addressing acute symptoms within an acute inpatient setting.
Mood disorders should be identified and treated promptly in order to avoid ongoing illness that might be ameliorated by early initiation of mood-stabilising treatments, such as lithium or antidepressants in those with comorbid or subsequent depression. Side effects and drug interactions should always be considered when prescribing mood stabilisers and antidepressants.
Consider potential adverse effects
DAs and PAs are associated with adverse effects including sedation, extrapyramidal side-effects, weight gain, sexual dysfunction and metabolic changes. These adverse effects are a common reason for medication discontinuation.
The lowest effective dose of medication which is associated with a lower likelihood of sedation, sexual dysfunction and metabolic complications should be prescribed. Preference should be made for initial pharmacotherapy with agents that have fewer adverse effects, with concomitant prescriptions of benzodiazepines or sedating antipsychotic to manage acute agitation. The latter should be withdrawn as psychosis resolves.
First line DA/PAs differ more in their side effect profiles than in their clinical efficacy. Choose medications that are associated with the least metabolic side effects including aripiprazole, brexpiprazole, cariprazine, or lurasidone.
Monitor metabolic parameters
Metabolic syndrome in combination with lifestyle factors contribute to poor physical health and increased mortality risk in people diagnosed with schizophrenia. Prompt identification, prevention and intervention strategies should be put into place for all people with early psychosis. Metabolic parameters should be monitored at treatment initiation and then at regular (3- to 6-monthly) intervals. Lifestyle interventions should be recommended at the time of medication commencement.
The role of long-acting injectable (LAI) antipsychotics in early psychosis
Despite the widely held attitude that LAI medications are invasive, coercive and reserved predominantly for people who are non-adherent with their medication, many people diagnosed with schizophrenia actually prefer this administration route to daily oral medication, and should be offered this choice early in their treatment. Long-acting injectable medications support improved adherence and superior outcomes compared to oral medications. They can facilitate adherence while psychosocial interventions are delivered.
Despite the widely held attitude that LAI medications are invasive, coercive and reserved predominantly for people who are non-adherent with their medication, many people diagnosed with schizophrenia actually prefer this administration route to daily oral medication, and should be offered this choice early in their treatment.
What if treatment-resistance occurs?
Clozapine should be considered as soon as treatment refractory criteria are met – that is, after two adequate trials of six to eight weeks each with two DA/PA agents have failed to provide symptom relief. Clozapine, where clinically indicated, should be commenced during the three year ‘critical window’ following first episode psychosis. Delays in clozapine commencement are associated with poor outcomes.
Quality of Care
Optimal prescribing in early psychosis improves recovery and outcomes in people with early psychosis.
About the Author
James leads the Child and Youth Research Group at the QIMR Berghofer Medical Research Institute. He also practices clinically as a Child and Youth Psychiatrist with the Metro North Mental Health Service in Brisbane, where he is the Director of the Early Psychosis Service. James is the recipient of a National Health and Medical Research Council (NHMRC)
Practitioner Fellowship (2016 - 2020), awarded for his research into prevention and intervention strategies to improve the mental health of adolescents.
The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.
AU-NPSCZ-0015. May 2022