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Ashley Baker:

Research has proven that early intervention following first episode psychosis is associated with improved patient outcomes.  So what psychopharmacology options are available?  And how do we decide which one is right for our patients?

Welcome to NeuroFrontiers on ReachMD.  I’m Psychiatric Nurse Practitioner Ashley Baker, and I’m speaking with Dr. Hannah Brown, who’s the Director of the Wellness and Recovery After Psychosis Program at Boston Medical Center and is also an Assistant Professor of Psychiatry at Boston University Chobanian and Avedisian School of Medicine. 

Dr. Brown, welcome to the program.

Dr. Brown:

Hi, Ashley.  It’s great to be here.  Thank you so much for having me.

Ashley Baker:

Thanks for coming on.  So to start us off, Dr. Brown, can you define first episode psychosis and which patients are at risk of experiencing this?

Dr. Brown:

Yeah.  So I think psychosis really means different things to different people, and people experience psychosis differently.  So in general, psychosis means a different way of perceiving the world or an alteration in a reality that we’re used to.  And when we think about psychosis, we often think about positive symptoms and negative symptoms of psychosis.  So positive symptoms of psychosis are experiences that are added to an individual’s world, and they include symptoms like auditory hallucinations or visual hallucinations, delusional beliefs, persecutory delusions, grandiose delusions, disorganized speech, disorganized thought process, or disorganized behavior.  And then there’s the negative symptoms of psychosis, which really I think about is a withdrawal from the world around us—so an individual could have decreased engagement in social activities, lack of motivation to do things, decreased feeling of emotions, decreased emotional expressiveness.  And so when we think about first episode psychosis, it may be in the context of a primary psychotic illness, like schizophrenia or schizoaffective disorder, or it may be in other settings, like a substance-induced psychosis or in the context of a medical illness.  So that’s what we hope to determine when we’re initially seeing people who have experienced a first episode of psychosis.

Ashley Baker:

So how would we diagnose the first episode psychosis versus another condition?  And in what settings do providers typically catch the first episode or see the first episode?

Dr. Brown:

We take a really good clinical history, with a goal of trying to understand the cause of the psychosis to help us with the diagnosis, and often we don’t know initially.  And as I mentioned, psychosis is really an umbrella term for symptoms and can be present in many different disease states.  So we first ask the patient questions to help us understand the course of illness, and we often talk not only to the individual who’s experiencing psychosis but maybe a family member, a loved one, caregiver, who have also witnessed the person experiencing psychosis. 

So for example, if someone describes a course of illness that has evolved over the past couple of years, they’ve experienced a prodromal phase, and prodromal phase is before the onset of the frank psychotic symptoms when things in a person’s world start to change a little bit.  So people may become more withdrawn from the world.  Their functioning may start to decline.  They don’t take as good self-care of themselves.  They may start having difficulties at work, in relationships.  And this can be really distressing for the individual and to the families who are witnessing this.  And in this prodromal phase, a lot of times individuals are diagnosed with depression or anxiety or ADHD, but then when they have the onset of these other positive psychotic symptoms, the clinical picture becomes more clear. 

One thing we try to do when we’re first thinking about diagnosis is trying to do a comprehensive medical screen to rule out big, underlying, medical causes of the psychosis, so we’ll do a basic medical workup.  We might do head imaging depending on the clinical history that we’ve obtained.  But if our clinical history has revealed what’s probably a first episode psychosis that’s in the context of a primary psychotic disorder, our medical workup might not be as in-depth. 

We also think about the substance-induced psychosis.  So I want to make the point that even if somebody may present with substance-induced psychosis, but they’re still at high risk for developing primary psychotic disorder if they’re regular high-potency cannabis users, and especially if they started at a young age, so we have to think, “Okay, maybe this is a substance-induced psychosis now, but they’re also at risk in the long term for developing continual psychotic symptoms.”

Ashley Baker:

So it sounds like what you’re saying is where you start with the diagnosis if there are heavy substances on board isn’t necessarily where you could end up.

Dr. Brown:

Exactly.  I always say we have our initial ideas in the beginning, but it’s really the longitudinal follow-up that really helps us with diagnosis.  Unfortunately, where we are now in schizophrenia diagnosis and treatment, we don’t have like a diagnostic marker.  We don’t have anything that will definitively give us a diagnosis.  It’s really rolling out everything else and taking a really good clinical history and looking at the clinical progression of the illness.

Ashley Baker:

For those just tuning in, you’re listening to NeuroFrontiers on ReachMD.  I’m Psychiatric Nurse Practitioner Ashley Baker, and I’m speaking with Dr. Hannah Brown about patients who experience first episode psychosis. 

So once you have decided that this likely is a first episode psychosis and not something else based on the medical rule-outs and the clinical evaluation, what treatment options would you consider?  And what is available?

Dr. Brown:

Well, we have multiple approaches to treatment.  I think about treatment, and I have specific goals that we work with the individual around achieving with the treatment.  So first, we really want to decrease the intensity or pervasiveness of the psychosis and alleviate the anxiety, the distress, other symptoms that can go along with psychotic symptoms.  We also think about preventing bad outcomes that are associated when individuals experience psychosis, like self-harm, decline in function, legal involvement, so we want to get treatment going as fast as possible.  And if we think about it, a lot of times first episode psychosis occurs at a really critical point in development, in this transitional age when people are really seeking their own independence, and psychotic symptoms can significantly impair that really key developmental phase, so we work with the individual so they are able to go back to work, go back to school, develop these relationships again that may have been so severely disrupted.  And then we want to prevent relapse. 

And then the big key is what we want to do is minimize the duration of untreated psychosis, or DUP.  So we know that individuals who have a shorter DUP—so DUP when they first start experiencing the symptoms to this treatment initiation have better response to medication, better symptom, and functional recovery, fewer negative symptoms—and we look at this time as really a window of opportunity to intervene early and consistently with treatment, so early identification and intervention, and then continued treatment is so key to better longitudinal outcomes. 

So what treatments are available?  We think about medications.  Medications are really important.  In fact, they’re necessary.  They’re a key part of treatment, but they’re not the only component of treatment.  We think about individual therapy.  We think about family psychoeducation, and peer support, and supported education and employment, so helping people go back to work, go back to school.  In terms of medication, our primary tool is antipsychotic medication, and antipsychotic medication is really good at treating the positive psychotic symptoms like I described but really not helpful in treating the negative symptoms, unfortunately, and the negative symptoms can be really impairing.  So antipsychotic medication is really good, but it also has its limitations, and it also has its side effects.

Ashley Baker:

You’ve done a really great job explaining to us what the best treatment outcomes can be and how to work collaboratively with our team to do that, but what are the biggest challenges or hurdles that you face as providers and as the treatment team when trying to provide the most comprehensive and best care for first episode patients?

Dr. Brown:

Yeah.  When it comes to treatment, we work really closely with the individual with psychosis, and we use a shared decision-making approach, so we discuss with the patient what their goals of treatment are, and in particular in treatment with medications, we try to set expectations up front.  So one challenge that we have when it comes to treatment is really we have an inability to predict treatment response, so we don’t know who’s going to have the best response to which medication.  And we share that with the patient up front, and we try to set the expectation that there might be some trials of different medications, that there might be side effects that they experience, so we monitor side effects very closely.  At every clinical visit, we go through the list of side effects that they may or may not be experiencing.  We tailor the medications accordingly, so if the dose is a little bit too high, we might have to drop the dose.  We might have to add another medication to help ameliorate the side effects.  So it can be a really challenging process sometimes just because we can’t predict treatment response, but what we really try to do is a patient-centered approach where the patient is actively involved in their treatment.

Another challenge that we often face is that of the concept of insight and insight into the illness, and I think a fundamental piece of a primary psychotic illness is often that the individual doesn’t have insight into the fact that they have an illness or that they may need treatment for the illness.  And of course, if you don’t think you have the illness or you don’t think your symptoms are severe, why would you take medication?  And certainly, why would you take medication that has terrible side effects?  So we think creatively and again, thinking with the patient, what are some benefits to medications?  If it’s not the psychotic symptoms, are there other things that could be helpful for treatment, like thinking more clearly or organizing your thoughts a little bit better.  And we try to frame the medications in as helpful in other ways.  Another big piece of treatment is really making sure our goals with treatment align with the patient’s and again that we’re paying close attention to the side effect monitoring.

Ashley Baker:

It sounds like you and your team do a really great job of meeting the patients where they’re at, and also aligning with their goals and trying to help them achieve everything that they would want to achieve with or without the diagnosis, which is very inspiring.

Dr. Brown:

I like to think that.

Ashley Baker:

This has been a great discussion about the unique psychiatric needs of our patients during first episode psychosis.  I want to thank my guest, Dr. Hannah Brown, for sharing her insights today.  Dr. Brown, it was wonderful speaking with you.

Dr. Brown:

You thank you very much, Ashley.

Ashley Baker:

For ReachMD, I’m Ashley Baker.  To access this and other episodes in our series, visit NeuroFrontiers on ReachMD.com, where you can Be Part of the Knowledge.  Thanks for listening.